1
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Ozcan EE, Turan OE, Akdemir B, Inevi UD, Yilancioglu RY, Baskurt AA, Alak C, Bayrak F. Comparison of electrophysiological characteristics of right- and left-sided Mahaim-type accessory pathways. J Cardiovasc Electrophysiol 2021; 32:360-369. [PMID: 33355963 DOI: 10.1111/jce.14852] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 11/26/2020] [Accepted: 12/13/2020] [Indexed: 12/01/2022]
Abstract
AIMS Mahaim-type accessory pathways (MAPs) are generally right-sided due to the embryological differentiation, but left-sided localization is also possible. This study aims to compare the clinical and electrophysiological characteristics of right- and left-sided MAPs. METHODS Of 251 patients diagnosed with AP by electrophysiological study between November 2015 and February 2020, 12 patients with MAP were included (right sided n = 8, left sided n = 4). MAP was diagnosed if; (1) no retrograde conduction; (2) anterograde decremental conduction; (3) adenosine sensitivity; and (4) Mahaim potential at successful ablation site were present. RESULTS Ten of twelve MAPs were clustered on the lateral walls of the mitral (n = 3, 75%) and tricuspid annuli (n = 7, 87.5%). Right-sided MAPs were mostly long pathways extending toward the conduction system whereas left-sided MAPs were short extending toward the neighboring myocardium. For right- and left-sided APs, the median QRS times were 129 and 156 ms (p = .042), the median VAbl -RVApex intervals were -12 and 64 ms (p = .007), the median QRS-V(His) intervals were 16 and 86 ms (p = .120), and the median VAbl -QRS interval was -8 and 12 ms (p = .017), respectively. Coexistence of dual atrioventricular node physiology was observed only in right-sided APs (n = 3, 37.5%). CONCLUSION MAPs are more typically located on the right but may rarely be seen on the left. Catheter ablation was associated with high success without complications.
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Affiliation(s)
- Emin Evren Ozcan
- Department of Cardiology, Dokuz Eylul University School of Medicine, Izmir, Turkey
| | - Oguzhan Ekrem Turan
- Department of Cardiology, Dokuz Eylul University School of Medicine, Izmir, Turkey
| | - Baris Akdemir
- Department of Cardiology, Faculty of Medicine, Goztepe Medicalpark Hospital, Bahcesehir University, Istanbul, Turkey
| | | | | | - Ahmet Anil Baskurt
- Department of Cardiology, Dokuz Eylul University School of Medicine, Izmir, Turkey
| | - Cetin Alak
- Department of Cardiology, Dokuz Eylul University School of Medicine, Izmir, Turkey
| | - Fatih Bayrak
- Department of Cardiology, Acibadem Mehmet Ali Aydinlar University School of Medicine, Istanbul, Turkey
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2
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Crinion D, Baranchuk A. Algorithms to Identify Accessory Pathways' Location on the 12-Lead Electrocardiogram. Card Electrophysiol Clin 2020; 12:465-474. [PMID: 33161996 DOI: 10.1016/j.ccep.2020.08.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The ability to estimate accessory pathway (AP) position enables pre-procedural planning, reduces mapping times, and improves risk estimates as part of the patient consent process. In this article, the nomenclature and important concepts of AP localization algorithms are outlined. An overview of three prominent algorithms is then provided. Each represents an era of invasive treatment of APs: surgical therapy, endocardial ablation, and contemporary electroanatomic mapping. In this manner, the premises, pitfalls, and evolution of AP localization algorithms are illustrated. In addition, the pertinent features of their work are distilled in a simplified topographic algorithm with the interventional electrophysiologist in mind.
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Affiliation(s)
- Derek Crinion
- Division of Cardiology, Queen's University, Kingston Health Sciences Centre, Kingston General Hospital Site, Kidd 3, 76 Stuart Street, Kingston, Ontario K7L 2V7, Canada
| | - Adrian Baranchuk
- Division of Cardiology, Queen's University, Kingston Health Sciences Centre, Kingston General Hospital Site, Kidd 3, 76 Stuart Street, Kingston, Ontario K7L 2V7, Canada.
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3
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Clinical Approach to Symptomatic and Asymptomatic Patients with Ventricular Pre-excitation. Card Electrophysiol Clin 2020; 12:527-539. [PMID: 33162001 DOI: 10.1016/j.ccep.2020.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Despite extensive knowledge of the physiopathology of ventricular pre-excitation, management of asymptomatic patients with this condition remains controversial.
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4
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Oesterle A, Lee AC, Voskoboinik A, Moss JD, Vedantham V, Walters TE, Lee BK, Tseng ZH, Gerstenfeld EP, Scheinman MM. Electrophysiologic approach to diagnosis and ablation of patients with permanent junctional reciprocating tachycardia associated with complex anatomy and/or physiology. J Cardiovasc Electrophysiol 2020; 31:3232-3242. [PMID: 33107135 DOI: 10.1111/jce.14788] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 10/04/2020] [Accepted: 10/11/2020] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Permanent junctional reciprocating tachycardia (PJRT) is a rare supraventricular tachycardia (SVT), typically involving a single decremental posteroseptal accessory pathway (AP). METHODS Four patients with long RP SVT underwent electrophysiology (EP) study and ablation. The cases were reviewed. RESULTS Case 1 recurred despite 3 prior ablations at the site of earliest retrograde atrial activation during orthodromic reciprocating tachycardia (ORT). Mapping during a repeat EP study demonstrated a prepotential in the coronary sinus (CS). Ablation over the earliest atrial activation in the CS resulted in dissociation of the potential from the atrium during sinus rhythm. The potential was traced back to the CS os and ablated. Case 2 underwent successful ablation at 6 o'clock on the mitral annulus (MA). ORT recurred and successful ablation was performed at 1 o'clock on the MA. Case 3 had tachycardia with variation in both V-A and A-H intervals which precluded the use of usual maneuvers so we used simultaneous atrial and ventricular pacing and introduced a premature atrial contraction with a closely coupled premature ventricular contraction. Case 4 had had two prior atrial fibrillation ablations with continued SVT over a decremental atrioventricular bypass tract that was successfully ablated at 5 o'clock on the tricuspid annulus. A second SVT consistent with a concealed nodoventricular pathway was successfully ablated at the right inferior extension of the AV nodal slow pathway. CONCLUSION We describe challenging cases of PJRT by virtue of complex anatomy, diagnostic features, and multiple arrhythmia mechanisms.
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Affiliation(s)
- Adam Oesterle
- Division of Cardiovascular Medicine, Department of Medicine, University of California Davis, Sacramento, California, USA
| | - Adam C Lee
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Aleksandr Voskoboinik
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Joshua D Moss
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Vasanth Vedantham
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Tomos E Walters
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Byron K Lee
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Zian H Tseng
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Edward P Gerstenfeld
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Melvin M Scheinman
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
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5
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Behjati Ardakani M, Dehghani F, Sarebanhassanabadi M, Yalameh A, Behjat M, Behjati Ardakani M, Shafiee M, Seyed Hosseini SM. Impact of Accessory Pathway Location on Electrophysiologic Characteristics and Ablation Success. Crit Pathw Cardiol 2020; 19:94-97. [PMID: 31895133 DOI: 10.1097/hpc.0000000000000206] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND To investigate the relationship between the location of accessory pathways, electrophysiologic characteristics, and ablation success in Wolfe-Parkinson-White (WPW) syndrome. METHODS Electrophysiologic study was performed in 178 patients for a pre-excitation syndrome. Accessory pathway location, anterograde or retrograde conduction, ablation success, and recurrence rate were evaluated. RESULTS Among 178 patients with WPW syndrome, the most frequent location of the accessory pathway was left lateral (39.3%) which had high ablation success rate (97%) and low recurrence rate (1%). A meaningful relationship exists between accessory pathway location and electrophysiologic characteristics. Ablation success rate was 89.7% and was statistically related to accessory pathway location. Recurrent occurred in 2.9% of our patients and was more frequent in right free wall and PJRT. CONCLUSIONS The location of accessory pathways has a great impact on conductivity, ablation success, and recurrence rate in WPW syndrome.
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6
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Miyama H, Takatsuki S, Kimura T, Mitamura H, Ogawa S. Unusual Permanent Form of Junctional Reciprocating Tachycardia Associated With an Accessory Pathway With Bidirectional Conduction. JACC Case Rep 2020; 2:245-246. [PMID: 34317213 PMCID: PMC8298563 DOI: 10.1016/j.jaccas.2019.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Revised: 10/18/2019] [Accepted: 12/09/2019] [Indexed: 11/23/2022]
Abstract
We describe an unusual case of permanent form of junctional reciprocating tachycardia in a patient with manifest Wolff-Parkinson-White syndrome. The electrophysiological study revealed an accessory pathway responsible for the tachycardia, revealing fast and nondecremental anterograde conduction and slow and decremental retrograde conduction that was successfully ablated from the middle cardiac vein. (Level of Difficulty: Advanced.)
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Affiliation(s)
- Hiroshi Miyama
- Division of Cardiology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Seiji Takatsuki
- Division of Cardiology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
- Address for correspondence: Dr. Seiji Takatsuki, Division of Cardiology, Department of Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjukuku, Tokyo 160-8582, Japan.
| | - Takehiro Kimura
- Division of Cardiology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Hideo Mitamura
- Division of Cardiology, Tachikawa Hospital, Tokyo, Japan
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7
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Uhm J, Kim J, Jin M, Kim I, Cho MS, Yang P, Yu HT, Kim T, Joung B, Pak H, Nam G, Choi K, Kim Y, Hwang C, Lee M. Radiofrequency catheter ablation of accessory pathways at the site of prior valve surgery. J Arrhythm 2019; 35:645-653. [PMID: 31410235 PMCID: PMC6686296 DOI: 10.1002/joa3.12213] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 06/02/2019] [Accepted: 06/09/2019] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Radiofrequency catheter ablation (RFCA) for accessory pathways (APs) at the site of prior valve surgery (VS) remains challenging. We aimed to clarify the factors associated with successful RFCA for such APs. METHODS Upon reviewing a RFCA registry and previous case reports, we included nine patients who underwent RFCA of APs at the site of prior VS (total-VS group; age, 34.0 [24.5-45.0] years; men, 4/9) and 196 patients who underwent RFCA of APs with no history of VS (no-VS group; age, 40.5 [23.0-54.0] years; men, 114/196). Electrophysiological features, procedural details, and outcomes were examined. RESULTS Accessory pathway exhibited decremental conduction in four of nine patients in the total-VS group. The number of RFCA attempts was significantly higher in the total-VS group than in the no-VS group (10.0 [4.5-14.5] vs 2.0 [1.0-3.0]; P < 0.001). In four patients who underwent mitral VS, successful RFCA was achieved using the transaortic approach, coronary sinus (CS) approach, or bipolar ablation. In three patients who underwent tricuspid VS, successful RFCA was achieved using the above-prosthetics or trans-prosthetics approach. In two patients, RFCA failed. The trans-prosthetics approach and bipolar ablation technique were effective. The transaortic and CS approaches were occasionally effective. The transseptal approach was ineffective. CONCLUSIONS Successful RFCA of APs at the site of prior VS can be achieved by detailed mapping of the areas both above and below the prosthetic valve, as well as by ensuring effective radiofrequency energy delivery using various catheter approaches and RFCA techniques.
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Affiliation(s)
- Jae‐Sun Uhm
- Division of Cardiology, Department of Internal Medicine, Severance HospitalYonsei University College of MedicineSeoulRepublic of Korea
| | - Jun Kim
- Department of Cardiology, Asan Medical Center, The Heart InstituteUniversity of Ulsan College of MedicineSeoulRepublic of Korea
| | - Moo‐Nyun Jin
- Division of Cardiology, Department of Internal Medicine, Severance HospitalYonsei University College of MedicineSeoulRepublic of Korea
| | - In‐Soo Kim
- Division of Cardiology, Department of Internal Medicine, Severance HospitalYonsei University College of MedicineSeoulRepublic of Korea
| | - Min Soo Cho
- Department of Cardiology, Asan Medical Center, The Heart InstituteUniversity of Ulsan College of MedicineSeoulRepublic of Korea
| | - Pil‐Sung Yang
- Division of Cardiology, Department of Internal Medicine, Severance HospitalYonsei University College of MedicineSeoulRepublic of Korea
| | - Hee Tae Yu
- Division of Cardiology, Department of Internal Medicine, Severance HospitalYonsei University College of MedicineSeoulRepublic of Korea
| | - Tae‐Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Severance HospitalYonsei University College of MedicineSeoulRepublic of Korea
| | - Boyoung Joung
- Division of Cardiology, Department of Internal Medicine, Severance HospitalYonsei University College of MedicineSeoulRepublic of Korea
| | - Hui‐Nam Pak
- Division of Cardiology, Department of Internal Medicine, Severance HospitalYonsei University College of MedicineSeoulRepublic of Korea
| | - Gi‐Byoung Nam
- Department of Cardiology, Asan Medical Center, The Heart InstituteUniversity of Ulsan College of MedicineSeoulRepublic of Korea
| | - Kee‐Joon Choi
- Department of Cardiology, Asan Medical Center, The Heart InstituteUniversity of Ulsan College of MedicineSeoulRepublic of Korea
| | - You‐Ho Kim
- Department of Cardiology, Asan Medical Center, The Heart InstituteUniversity of Ulsan College of MedicineSeoulRepublic of Korea
| | - Chun Hwang
- Department of CardiologyRevere HealthProvoUtah
| | - Moon‐Hyoung Lee
- Division of Cardiology, Department of Internal Medicine, Severance HospitalYonsei University College of MedicineSeoulRepublic of Korea
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8
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Kaiser DW, Nasir JM, Liem LB, Brodt C, Motonaga KS, Ceresnak SR, Turakhia MP, Dubin AM. A novel pacing maneuver to verify the postpacing interval minus the tachycardia cycle length while adjusting for decremental conduction: Using "dual-chamber entrainment" for improved supraventricular tachycardia discrimination. Heart Rhythm 2018; 16:717-723. [PMID: 30465902 DOI: 10.1016/j.hrthm.2018.11.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND The postpacing interval (PPI) minus the tachycardia cycle length (TCL) is frequently used to investigate tachycardias. However, a variety of issues (eg, failure to entrain, decremental conduction, and oscillating TCLs) can make interpretation of the PPI-TCL challenging. OBJECTIVE The purpose of this study was to investigate a novel maneuver to confirm the PPI-TCL value without using either the ventricular PPI or the TCL interval and to assess the ability of this maneuver to identify decremental conduction and differentiate supraventricular tachycardias. METHODS We analyzed 77 intracardiac recordings from patients (age 25 ± 20 years; 40 female) who underwent catheter ablation of atrioventricular nodal reentrant tachycardia (AVNRT) or orthodromic reciprocating tachycardia (ORT) with a concealed pathway. We calculated the PPI-TCL, the AH-corrected PPI-TCL, and estimated the PPI-TCL using "dual-chamber entrainment" calculated as [PPIV - TCL = Stim(A→V) + Stim(V→A) - PPIA]. RESULTS The PPI-TCL calculated by dual-chamber entrainment highly correlated with the observed and AH-corrected PPI-TCL (R2 = 0.79 and 0.96, respectively; P <.001]. A dual-chamber entrainment PPI-TCL value of 80 ms correctly differentiated all AVNRT from septal ORT cases, whereas the standard PPI-TCL and AH-corrected PPI-TCL methods were incorrect in 14% and 6% of cases, respectively. Dual-chamber entrainment identified 3 ± 10 ms of additional decremental conduction beyond AH prolongation, including 4 pathways with significant (>10 ms) decrement. CONCLUSION Dual-chamber entrainment estimates the PPI-TCL value without using either the ventricular PPI or the TCL interval. This maneuver adjusts for all decremental conduction, including within concealed pathways, where a dual-chamber entrainment PPI-TCL value >80 ms favors AVNRT over ORT. This maneuver can be used to verify the observed PPI-TCL value in challenging cases.
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Affiliation(s)
- Daniel W Kaiser
- El Camino Hospital, Mountain View, California; St Helena Hospital, St Helena, California.
| | - Javed M Nasir
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - L Bing Liem
- El Camino Hospital, Mountain View, California; St Helena Hospital, St Helena, California
| | - Chad Brodt
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Kara S Motonaga
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Scott R Ceresnak
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Mintu P Turakhia
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Anne M Dubin
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
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9
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Santilli RA, Mateos Pañero M, Porteiro Vázquez DM, Perini A, Perego M. Radiofrequency catheter ablation of accessory pathways in the dog: the Italian experience (2008-2016). J Vet Cardiol 2018; 20:384-397. [PMID: 30131290 DOI: 10.1016/j.jvc.2018.07.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 07/20/2018] [Accepted: 07/23/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Accessory pathways (APs) in dogs are mostly right-sided, display nondecremental conduction, and mediate atrioventricular reciprocating tachycardias (AVRTs). Radiofrequency catheter ablation (RFCA) is considered the first-line therapy in human patients to abolish electrical conduction along APs. ANIMALS Seventy-six consecutive client-owned dogs. MATERIAL AND METHODS Retrospective study to describe the precise anatomical distribution and the electrophysiologic characteristics of APs in a large population of dogs and to evaluate long-term success and complication rates of RFCA. RESULTS Eighty-three APs were identified in 76 dogs (92.1% with single APs and 7.9% with multiple APs); 96.4% were right-sided, 3.6% left-sided. Conduction along the APs was unidirectional and retrograde in 68.7% of the cases and bidirectional in 31.3%. Accessory pathways presented retrograde decremental properties in 6.5% of the cases. They mediated orthodromic AVRT in 92.1% of the cases and permanent junctional reciprocating tachycardia in 6.5%. In one case, no AVRT could be induced. In 97.4% of dogs, RFCA was attempted with an acute success rate of 100%. In 7.7% of cases, recurrence of the tachycardia occurred within 18 months, followed by a second definitively successful ablation. A major complication requiring pacemaker implantation was identified in 2.6% of dogs. DISCUSSION Accessory pathway distribution and electrophysiologic properties in these 76 dogs were similar to previous report. Long-term success and complication rates of RFCA in dogs appeared very similar to results of humans. CONCLUSION Radiofrequency catheter ablation of APs can be performed with a high success rate and low incidence of complications.
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Affiliation(s)
- R A Santilli
- Clinica Veterinaria Malpensa, Viale Marconi 27, 21017 Samarate, Varese, Italy.
| | - M Mateos Pañero
- Clinica Veterinaria Malpensa, Viale Marconi 27, 21017 Samarate, Varese, Italy
| | | | - A Perini
- Clinica Veterinaria Malpensa, Viale Marconi 27, 21017 Samarate, Varese, Italy
| | - M Perego
- Clinica Veterinaria Malpensa, Viale Marconi 27, 21017 Samarate, Varese, Italy
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10
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Uhm JS, Choi JI, Baek YS, Yu HT, Yang PS, Kim YG, Oh SK, Park HS, Lee KN, Kim TH, Shim J, Joung B, Pak HN, Lee MH, Kim YH. Electrophysiological features and radiofrequency catheter ablation of supraventricular tachycardia in patients with persistent left superior vena cava. Heart Rhythm 2018; 15:1634-1641. [PMID: 29953955 DOI: 10.1016/j.hrthm.2018.06.034] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND The electrophysiological features and roles of persistent left superior vena cava (PLSVC) in supraventricular tachycardia (SVT) are not known. OBJECTIVE The purpose of this study was to elucidate the electrophysiological features and roles of PLSVC in patients with SVT. METHODS We included 37 patients with PLSVC (mean age 43.5 ± 17.1 years; 35.1% men) and 510 patients without PLSVC (mean age 43.9 ± 18.8 years; 48.2% men) who underwent an electrophysiology study for SVT. The number of induced tachycardias, location of the slow pathway (SP) or accessory pathway (AP), and radiofrequency catheter ablation (RFCA) outcomes were compared between patients with and without PLSVC. During RFCA of the left AP, a coronary sinus (CS) catheter was placed into the left superior vena cava (left superior vena cava group) or the great cardiac vein (great cardiac vein group). The RFCA outcomes were compared between the groups. RESULTS In patients with PLSVC, 40 tachycardias were induced: atrioventricular nodal reentrant tachycardia (AVNRT) (n = 19), atrioventricular reentrant tachycardia (n = 17), and focal atrial tachycardia (n = 4). Among patients with AVNRT, an SP in the CS was significantly more frequent in patients with PLSVC than in those without PLSVC (47.4% vs 3.8%; P < .001). In patients with the left AP, the number of RFCA attempts and recurrence were lower in the great cardiac vein group than in the left superior vena cava group. CONCLUSION An SP in the CS is prevalent in patients with AVNRT and PLSVC. It is useful to place a CS catheter into the great cardiac vein in patients with a left AP and PLSVC.
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Affiliation(s)
- Jae-Sun Uhm
- Division of Cardiology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jong-Il Choi
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine, Korea University Medical Center, Seoul, Korea
| | - Yong Soo Baek
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine, Korea University Medical Center, Seoul, Korea
| | - Hee Tae Yu
- Division of Cardiology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Pil-Sung Yang
- Division of Cardiology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yun Gi Kim
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine, Korea University Medical Center, Seoul, Korea
| | - Suk-Kyu Oh
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine, Korea University Medical Center, Seoul, Korea
| | - Hee-Soon Park
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine, Korea University Medical Center, Seoul, Korea
| | - Kwang No Lee
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine, Korea University Medical Center, Seoul, Korea
| | - Tae-Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jaemin Shim
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine, Korea University Medical Center, Seoul, Korea
| | - Boyoung Joung
- Division of Cardiology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Moon-Hyoung Lee
- Division of Cardiology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
| | - Young-Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine, Korea University Medical Center, Seoul, Korea.
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11
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Hill AC, Silka MJ, Wee CP, Bar-Cohen Y. Characteristics of Decremental Accessory Pathways in Children. Circ Arrhythm Electrophysiol 2016; 9:CIRCEP.116.004190. [DOI: 10.1161/circep.116.004190] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 09/16/2016] [Indexed: 11/16/2022]
Abstract
Background—
Although retrograde decremental accessory pathways (DAPs) are thought to typically present as permanent junctional reciprocating tachycardia (permanent junctional reciprocating tachycardia), they may also be diagnosed unexpectedly during electrophysiology study. We aimed to compare the clinical and electrophysiological characteristics of patients with DAPs to an age-matched cohort with nondecremental accessory pathways.
Methods and Results—
We retrospectively studied pediatric patients (<21 years of age) with retrograde DAPs and an age-matched control population with nondecremental accessory pathways who underwent electrophysiology study between 2005 and 2014. Decrement was defined as rate-dependent prolongation of the local ventriculo-atrial time by >30 ms. Twenty-six patients with DAPs were compared with 73 controls (mean age at electrophysiology study 9.8±5.7 and 10.3±5.2 years, respectively [
P
=nonsignificant]). Compared with controls, patients with DAPs had more frequent syncope (5/26 [19%] versus 3/73 [4%];
P
=0.02) and ventricular dysfunction (6/26 [23%] versus 4/73 [6%];
P
=0.04). Only 11 (42%) DAP patients manifested clinical permanent junctional reciprocating tachycardia, and these patients had more syncope (5/11 [45%] versus 0/15 [0%];
P
<0.01), slower orthodromic reciprocating tachycardia (176±44 beats per minute versus 229±31 beats per minute;
P
=0.001), and longer ventriculo-atrial times (mean maximum ventriculo-atrial times of 283±116 ms versus 208±42 ms;
P
=0.02) compared with those with DAPs without clinical permanent junctional reciprocating tachycardia. DAPs and controls had similar rates of acute ablation success (23/26 [89%] versus 67/73 [92%];
P
=nonsignificant) and recurrences (1/23 [4%] versus 2/67 [3%];
P
=nonsignificant).
Conclusions—
The majority of pediatric patients with DAPs do not present with clinical permanent junctional reciprocating tachycardia. DAPs are associated with more severe symptoms, but ablation outcomes are similar to those of age-matched controls.
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Affiliation(s)
- Allison C. Hill
- From the Division of Cardiology, Children’s Hospital Los Angeles and Keck School of Medicine, University of Southern California (A.C.H., M.J.S., Y.B.-C.); and Biostatistics Core, Children’s Hospital, Los Angeles CA (C.P.W.)
| | - Michael J. Silka
- From the Division of Cardiology, Children’s Hospital Los Angeles and Keck School of Medicine, University of Southern California (A.C.H., M.J.S., Y.B.-C.); and Biostatistics Core, Children’s Hospital, Los Angeles CA (C.P.W.)
| | - Choo Phei Wee
- From the Division of Cardiology, Children’s Hospital Los Angeles and Keck School of Medicine, University of Southern California (A.C.H., M.J.S., Y.B.-C.); and Biostatistics Core, Children’s Hospital, Los Angeles CA (C.P.W.)
| | - Yaniv Bar-Cohen
- From the Division of Cardiology, Children’s Hospital Los Angeles and Keck School of Medicine, University of Southern California (A.C.H., M.J.S., Y.B.-C.); and Biostatistics Core, Children’s Hospital, Los Angeles CA (C.P.W.)
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Nakamura K, Naito S, Kaseno K, Oshima S. WITHDRAWN: Antegrade and retrograde decremental conduction properties of an accessory pathway associated with the coronary sinus musculature. Indian Pacing Electrophysiol J 2015. [DOI: 10.1016/j.ipej.2015.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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13
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Nakamura K, Naito S, Kaseno K, Oshima S. Antegrade and retrograde decremental conduction properties of an accessory pathway associated with the coronary sinus musculature. Indian Pacing Electrophysiol J 2015; 15:55-61. [PMID: 25852243 PMCID: PMC4380695 DOI: 10.1016/s0972-6292(16)30842-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
A 32-year-old man underwent catheter ablation of an orthodromic atrioventricular reentrant tachycardia. The sinus rhythm electrocardiogram exhibited a normal PQ interval and no delta waves, but atrial pacing produced a prolonged PQ interval and wide QRS morphology with right bundle-branch block due to antegrade accessory pathway (AP) conduction. During the tachycardia, atrial double potentials consisting of the coronary sinus musculature (CSM) and left atrial (LA) potentials were observed. Ventricular extrastimulation exhibited retrograde decremental conduction with an identical atrial activation sequence as during the tachycardia. A radiofrequency application within the posterolateral CS during ventricular pacing eliminated the CSM-LA conduction and concomitantly the ventriculoatrial conduction via the AP was abolished. In this case, the CSM was associated with the bidirectional decremental conduction properties of the AP, and the antegrade slow conduction resulted in the absence of a shortening of the PQ interval and delta waves during sinus rhythm despite the continuous presence of antegrade AP conduction.
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Affiliation(s)
- Kohki Nakamura
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma 371-0004, Japan
| | - Shigeto Naito
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma 371-0004, Japan
| | - Kenichi Kaseno
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma 371-0004, Japan
| | - Shigeru Oshima
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma 371-0004, Japan
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Ergul Y, Akdeniz C, Kiplapinar N, Tuzcu V. Successful cryoablation of Mahaim tachycardia in a child with Ebstein's anomaly. Pediatr Cardiol 2014; 34:1890-5. [PMID: 22806715 DOI: 10.1007/s00246-012-0434-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2012] [Accepted: 07/03/2012] [Indexed: 11/25/2022]
Abstract
Mahaim fibers with decremental atrioventricular (AV) node-like conduction properties comprise less than 3 % of accessory pathways. Radiofrequency ablation of right atriofascicular pathways guided by a distinct Mahaim potential detected at the anterolateral to posterolateral tricuspid annulus or in the right ventricular free wall is a safe and highly effective treatment method. The case report presents a 16-year-old boy with Ebstein's anomaly and symptomatic wide complex tachyarrhythmia. The electrophysiologic study and the entire ablation procedure were performed using a three-dimensional mapping system (EnSite Velocity; St. Jude Medical Inc., St. Paul, MN, USA). No fluoroscopy was used during the procedure. Electrophysiologic evaluation demonstrated typical atrioventricular nodal reentrant tachycardia and Mahaim tachycardia with a wide QRS and a left bundle branch block pattern. After Mahaim potential was located at the lateral tricuspid annulus, successful cryoablation was performed with an 8-mm-tip catheter followed by slow pathway ablation to eliminate typical atrioventricular nodal reentrant tachycardia. Cryoablation with an 8-mm-tip catheter can be an alternative treatment option for children with Mahaim tachycardia.
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Affiliation(s)
- Yakup Ergul
- Pediatric Cardiology/Electrophysiology, Mehmet Akif Ersoy Cardiovascular Research and Training Hospital, Istanbul, Turkey
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15
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Shenthar J, Rai MK. Preexcited tachycardia mimicking outflow tract ventricular tachycardia ablated from the left coronary cusp. J Cardiovasc Electrophysiol 2014; 25:653-6. [PMID: 24654607 DOI: 10.1111/jce.12412] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Revised: 03/11/2014] [Accepted: 03/12/2014] [Indexed: 11/28/2022]
Affiliation(s)
- Jayaprakash Shenthar
- Electrophysiology Unit, Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, Karnataka, India
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MAH DOUGLASY, SHERWIN ELIZABETHD, ALEXANDER MARKE, CECCHIN FRANK, ABRAMS DOMINICJ, WALSH EDWARDP, TRIEDMAN JOHNK. The Electrophysiological Characteristics of Accessory Pathways in Pediatric Patients with Intermittent Preexcitation. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2013; 36:1117-22. [DOI: 10.1111/pace.12144] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Revised: 02/14/2013] [Accepted: 02/15/2013] [Indexed: 11/29/2022]
Affiliation(s)
- DOUGLAS Y. MAH
- Department of Cardiology; Boston Children's Hospital; Boston Massachusetts
- the Department of Pediatrics; Harvard Medical School; Boston Massachusetts
| | - ELIZABETH D. SHERWIN
- Department of Cardiology; Boston Children's Hospital; Boston Massachusetts
- the Department of Pediatrics; Harvard Medical School; Boston Massachusetts
| | - MARK E. ALEXANDER
- Department of Cardiology; Boston Children's Hospital; Boston Massachusetts
- the Department of Pediatrics; Harvard Medical School; Boston Massachusetts
| | - FRANK CECCHIN
- Department of Cardiology; Boston Children's Hospital; Boston Massachusetts
- the Department of Pediatrics; Harvard Medical School; Boston Massachusetts
| | - DOMINIC J. ABRAMS
- Department of Cardiology; Boston Children's Hospital; Boston Massachusetts
- the Department of Pediatrics; Harvard Medical School; Boston Massachusetts
| | - EDWARD P. WALSH
- Department of Cardiology; Boston Children's Hospital; Boston Massachusetts
- the Department of Pediatrics; Harvard Medical School; Boston Massachusetts
| | - JOHN K. TRIEDMAN
- Department of Cardiology; Boston Children's Hospital; Boston Massachusetts
- the Department of Pediatrics; Harvard Medical School; Boston Massachusetts
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Cohen MI, Triedman JK, Cannon BC, Davis AM, Drago F, Janousek J, Klein GJ, Law IH, Morady FJ, Paul T, Perry JC, Sanatani S, Tanel RE. PACES/HRS expert consensus statement on the management of the asymptomatic young patient with a Wolff-Parkinson-White (WPW, ventricular preexcitation) electrocardiographic pattern: developed in partnership between the Pediatric and Congenital Electrophysiology Society (PACES) and the Heart Rhythm Society (HRS). Endorsed by the governing bodies of PACES, HRS, the American College of Cardiology Foundation (ACCF), the American Heart Association (AHA), the American Academy of Pediatrics (AAP), and the Canadian Heart Rhythm Society (CHRS). Heart Rhythm 2012; 9:1006-24. [PMID: 22579340 DOI: 10.1016/j.hrthm.2012.03.050] [Citation(s) in RCA: 215] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2012] [Indexed: 10/28/2022]
Affiliation(s)
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- Arizona Pediatric Cardiology Consultants & Phoenix Children's Hospital, Phoenix, AZ, USA
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ISSA ZIADF. Mechanism of Wide Complex Tachycardia in a Structurally Normal Heart. J Cardiovasc Electrophysiol 2009; 20:1074-6. [DOI: 10.1111/j.1540-8167.2009.01482.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Sumitomo N, Fukuhara J, Mugishima H, Sugi K. Decremental accessory pathway conduction after ablation and antidromic atrioventricular reciprocating tachycardia 8 years after successful radiofrequency ablation. J Cardiovasc Electrophysiol 2009; 20:818-21. [PMID: 19207774 DOI: 10.1111/j.1540-8167.2008.01404.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION This is a rare case of antidromic reciprocating tachycardia developing 8 years after successful catheter ablation. RESULT A 15-year-old girl had recurrence of palpitations 8 years after the ablation of manifest right posteroseptal accessory pathway. Atrial burst pacing revealed Wenckebach atrioventricular conduction with preexcitation. Wide QRS tachycardia with identical morphology to sinus rhythm associated with retrograde His potential recorded immediately after the V-wave was induced by isoproterenol infusion. Atrial premature stimulus applied at the identical timing of His potential advanced the subsequent ventricular beat and His potential. CONCLUSION Catheter ablation may produce decremental accessory pathway conduction and rarely cause antidromic atrioventricular reciprocating tachycardia. This may be explained by a presence of "de novo" accessory pathway with decremental conduction properties that became manifest after the first ablation.
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Affiliation(s)
- Naokata Sumitomo
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan.
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Lee KW, Badhwar N, Scheinman MM. Supraventricular Tachycardia—Part II: History, Presentation, Mechanism, and Treatment. Curr Probl Cardiol 2008; 33:557-622. [DOI: 10.1016/j.cpcardiol.2008.06.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Electrophysiological study and catheter ablation of a Mahaim fibre located at the mitral annulus–aorta junction. J Interv Card Electrophysiol 2008; 23:153-7. [DOI: 10.1007/s10840-008-9279-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2008] [Accepted: 05/15/2008] [Indexed: 10/21/2022]
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Willems S, Eckardt L, Hoffmann E, Klemm H, Pitschner HF, Reithmann C, Tebbenjohanns J, Zrenner B. [Guideline invasive electrophysiological diagnostics]. Clin Res Cardiol 2008; 96:634-51. [PMID: 17687504 DOI: 10.1007/s00392-007-0572-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- S Willems
- Universitäres Herzzentrum GmbH, Klinik für Kardiologie, Martinistrasse 52, 20246, Hamburg, Germany.
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Santilli RA, Spadacini G, Moretti P, Perego M, Perini A, Crosara S, Tarducci A. Anatomic distribution and electrophysiologic properties of accessory atrioventricular pathways in dogs. J Am Vet Med Assoc 2007; 231:393-8. [PMID: 17669040 DOI: 10.2460/javma.231.3.393] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To evaluate the anatomic distribution and electrophysiologic properties of accessory pathways (APs) in dogs. DESIGN Case series. ANIMALS 10 dogs with tachyarrhythmias associated with an AP. PROCEDURES Each dog underwent electrophysiologic testing to determine the inducibility of documented and undocumented arrhythmias and to identify location, conduction properties, and antegrade and retrograde effective refractory periods of the APs. Radiofrequency catheter ablation was then performed. RESULTS 15 APs were identified; 7 dogs each had a single AP, and 3 had multiple APs. Fourteen of the 15 APs were right-sided (6 right free wall, 4 posteroseptal, 3 midseptal, and 1 anteroseptal), and 1 was left-sided (left free wall). All APs conducted in an all-or-none fashion. Unidirectional retrograde conduction was observed in 11 APs, and bidirectional conduction was observed in 4. All documented tachyarrhythmias could be induced during electrophysiologic testing; atrial fibrillation was also inducible in 2 dogs. Mean +/- SD cycle duration of orthodromic atrioventricular reciprocating tachycardia was 215.80 +/- 44.87 milliseconds. Mean shortest R-R interval during atrial fibrillation was 247.33 +/- 83.17 milliseconds. CONCLUSIONS AND CLINICAL RELEVANCE Results suggested that in dogs, most APs are right-sided, had unidirectional retrograde conduction, and are associated with various arrhythmias, including orthodromic atrioventricular reciprocating tachycardia and atrial fibrillation without evidence of pre-excitation.
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Affiliation(s)
- Roberto A Santilli
- Clinica Veterinaria Malpensa, Via Marconi, 27, 21017 Samarate, Varese, Italy
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Pedrote A, Arana E, García-Riesco L, Errazquin F. [Ablation of a Mahaim accessory pathway connected to the left ventricle]. Rev Esp Cardiol 2007; 60:665-7. [PMID: 17580058 DOI: 10.1157/13107126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Arya A, Haghjoo M, Jafari A, Emkanjoo Z, Fazelifar AF, Dehghani MR, Sadr-Ameli MA. Effect of conduction mode and location on electrophysiologic characteristics of accessory pathways. Am J Cardiol 2005; 95:1250-2. [PMID: 15878005 DOI: 10.1016/j.amjcard.2005.01.060] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2004] [Revised: 01/17/2005] [Accepted: 01/17/2005] [Indexed: 10/25/2022]
Abstract
The conduction properties of accessory pathways (APs) are independent of location and conduction mode (except in patients with multiple, Mahaim, and slowly conducting APs). Patients with right-sided APs show higher rates of atrial fibrillation and longer arrhythmia cycle length due to slower anterograde conduction over the atrioventricular node during atrioventricular reentrant tachycardia.
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Manita M, Kaneko Y, Kurabayashi M, Yeh SJ, Wen MS, Wang CC, Lin FC, Wu D. Electrophysiological characteristics and radiofrequency ablation of accessory pathways with slow conductive properties. Circ J 2004; 68:1152-9. [PMID: 15564699 DOI: 10.1253/circj.68.1152] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Atrioventricular accessory pathways (AP) with unusually long ventriculo-atrial (VA) conduction times are present in a significant subset of patients with the Wolff-Parkinson-White (WPW) syndrome, not including patients with the permanent form of atrioventricular junctional reciprocating tachycardia. METHODS AND RESULTS We compared the electrophysiological characteristics and outcomes after radiofrequency (RF) ablation in 34 patients with the WPW syndrome, a VA interval >80 ms, and paroxysmal tachycardia with an RP/PR ratio <1 (the slow group), vs 80 patients with WPW syndrome and a VA interval <80 ms (the fast group). AP were found in the posteroseptal region significantly more often in the slow than in the fast group. In addition, the decremental conductive properties of the AP were more common in the slow than in the fast group. Catheter ablation of AP was highly successful in both groups, although ablation required a greater number of RF applications and longer procedure times in the slow group, especially for AP with decremental conductive properties. CONCLUSIONS A posteroseptal AP location was more common in AP associated with long conduction times than in AP with typical conductive properties. Both types of AP were successfully ablated, although the slow group required longer procedures and more RF energy deliveries.
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Affiliation(s)
- Mamoru Manita
- Department of Medicine and Biological Science, Gunma University Graduate School of Medicine, Showa-machi, Maebashi, Gunma, Japan.
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Lin KH, Kuo CT, Luqman N, Hsu KH, Wang CL, Hsu TS, Lee YS. Electrophysiological characteristics of accessory pathways with prolonged retrograde conduction. Pacing Clin Electrophysiol 2004; 27:1250-6. [PMID: 15461715 DOI: 10.1111/j.1540-8159.2004.00616.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Electrophysiological characteristics of an accessory pathway (AP) with a long ventriculoatrial (VA) interval (arbitrarily defined as > or = 50 ms and absence of continuous electrical activity) and no retrograde decremental property are described in this study. Fifteen patients (group 1) were compared with 171 patients with normal VA conduction (group 2). Mean VA conduction time was 77 +/- 24 versus 34 +/- 12 ms in group 1 versus group 2, respectively. Group 1 patients were older (55 +/- 14 vs 40 +/- 14 years), the male to female ratio was higher (2.8 vs 1.6), and APs were more prevalent on the right (60%) but manifest APs were lower (20% vs 54%) compared to group 2 patients (P < 0.05 in all cases). QRS morphology during induced atrioventricular reciprocating tachycardia was identical in both groups but the tachycardia cycle length was longer in group 1 (373 +/- 29 vs 344 +/- 50 ms, P < 0.05). Retrograde AP block cycle length and effective refractory period were greater in group 1 (362 +/- 59 vs 293 +/- 57 ms; 330 +/- 58 vs 273 +/- 55 ms, both P < 0.05). Adenosine (up to 18 mg) and verapamil (5-10 mg) failed to block the VA conduction via AP during ventricular pacing. In group 1 the number of radiofrequency lesions for a successful ablation were significantly less (3 +/- 2 vs 6 +/- 5, P < 0.05). In conclusion, APs with a long VA interval and no decremental retrograde conduction have electrophysiological characteristics that are different from those with a short VA interval. Role of aging deserves further exploration.
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Affiliation(s)
- Kuo-Hung Lin
- Department of Cardiology, Chang Gung University and Chang Gung Memorial Hospital, Linkou, Taiwan
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28
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Chen HY, Tai CT, Chen SA. Long RP tachycardia after injury of accessory atrioventricular pathway conduction by radiofrequency catheter ablation. Pacing Clin Electrophysiol 2003; 26:765-7. [PMID: 12698679 DOI: 10.1046/j.1460-9592.2003.00129.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Hung-Yi Chen
- Taipei Municipal Hoping Hospital, Taipei, Taiwan
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Coppess MA, Altemose GT, Jayachandran JV, Al-Sheikh T, Zipes DP, Miller JM. Unusual features of intermediate septal bypass tracts. J Cardiovasc Electrophysiol 2000; 11:730-5. [PMID: 10921788 DOI: 10.1111/j.1540-8167.2000.tb00042.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Intermediate septal (IS) AV bypass tracts, located along the tricuspid annulus between the His bundle and coronary sinus os, lie in close proximity to the AV node. Surgical or catheter ablation of IS bypass tracts incurs increased risk for development of complete heart block. We report additional unusual features of some IS bypass tracts that distinguish them from typical bypass tracts in other anatomic regions. METHODS AND RESULTS We analyzed a consecutive series of 150 patients with a history of Wolff-Parkinson-White syndrome and supraventricular tachycardia who underwent ablation of bypass tracts. We studied the incidence and characteristics of AV conduction of IS bypass tracts compared with bypass tracts in other locations. Of the 150 patients in the study, 21 had an IS bypass tract (all had anterograde AV conduction). Ten (48%) of these 21 IS bypass tracts demonstrated anterograde decremental properties with atrial pacing versus 3 (2%) of 129 non-IS bypass tracts (P < 0.001). During ablation, a change in delta wave morphology before total loss of conduction in the IS bypass tract also occurred in 3 (14%) of 21 IS bypass tracts versus 0 of 129 non-IS bypass tracts (P = 0.0004). During ablation, a change in P wave to delta wave interval occurred in 4 (19%) of 21 IS bypass tracts versus 0 of 129 non-IS bypass tracts (P < 0.0001). One IS patient exhibited retrograde Wenckebach block in the bypass tract, and two IS patients showed loss of retrograde bypass tract conduction after ablation attempts that first changed the delta wave morphology. No non-IS patient had these features (P < 0.0001 for each comparison). CONCLUSION Some IS bypass tracts have unusual properties that distinguish them from bypass tracts in other locations, perhaps due to the presence of multiple ventricular insertions of the bypass tract. It is possible that some cases represent true "nodoventricular" pathways.
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Affiliation(s)
- M A Coppess
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, USA
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Hluchy J, Schickel S, Jörger U, Jurkovicova O, Sabin GV. Electrophysiologic characteristics and radiofrequency ablation of concealed nodofascicular and left anterograde atriofascicular pathways. J Cardiovasc Electrophysiol 2000; 11:211-7. [PMID: 10709718 DOI: 10.1111/j.1540-8167.2000.tb00323.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION True nodoventricular or nodofascicular pathways and left-sided anterograde decremental accessory pathways (APs) are considered rare findings. METHODS AND RESULTS Two unusual patients with paroxysmal supraventricular tachycardia were referred for radiofrequency (RF) ablation. Both patients had evidence of dual AV nodal conduction. In case 1, programmed atrial and ventricular stimulation induced regular tachycardia with a narrow QRS complex or episodes of right and left bundle branch block not altering the tachycardia cycle length and long concentric ventriculoatrial (VA) conduction. Ventricular extrastimuli elicited during His-bundle refractoriness resulted in tachycardia termination. During the tachycardia, both the ventricles and the distal right bundle were not part of the reentrant circuit. These findings were consistent with a concealed nodofascicular pathway. RF ablation in the right atrial mid-septal region with the earliest atrial activation preceded by a possible AP potential resulted in tachycardia termination and elimination of VA conduction. In case 2, antidromic reciprocating tachycardia of a right bundle branch block pattern was considered to involve an anterograde left posteroseptal atriofascicular pathway. For this pathway, decremental conduction properties as typically observed for right atriofascicular pathways could be demonstrated. During atrial stimulation and tachycardia, a discrete AP potential was recorded at the atrial and ventricular insertion sites and along the AP. Mechanical conduction block of the AP was reproducibly induced at the annular level and at the distal insertion site. Successful RF ablation was performed at the mitral annulus. CONCLUSION This report describes two unusual cases consistent with concealed nodofascicular and left anterograde atriofascicular pathways, which were ablated successfully without impairing normal AV conduction system.
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Affiliation(s)
- J Hluchy
- Department of Cardiology and Angiology, Elisabeth Hospital, Essen, Germany
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Kawabata M, Nawata H, Hirao K, Miyasaka N, Kawara T, Hiejima K, Suzuki F. Marked anterograde decremental conduction over a rapidly conducting accessory pathway after radiofrequency ablation. J Electrocardiol 2000; 33:71-8. [PMID: 10691177 DOI: 10.1016/s0022-0736(00)80103-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We report on a patient with the Wolff-Parkinson-White syndrome who temporarily exhibited a marked anterograde decremental conduction over a rapidly conducting accessory atrioventricular pathway after successful radiofrequency ablation. By recording the intracardiac electrogram via the ablation catheter placed at the successful ablation site, we were able to exclude the possibility of the occurrence of anterograde decremental conduction in the atrial or ventricular myocardium between the accessory pathway and the recording electrodes.
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Affiliation(s)
- M Kawabata
- First Department of Internal Medicine, School of Medicine, Tokyo Medical and Dental University, Japan
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33
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Ai T, Horie M, Washizuka T, Albrecht C, Nishimoto T, Obayashi K, Tsuchiya K, Watanuki M, Sasayama S. Successful radiofrequency current catheter ablation of accessory atrioventricular pathway after tricuspid replacement in Ebstein's anomaly. JAPANESE CIRCULATION JOURNAL 1998; 62:791-3. [PMID: 9805266 DOI: 10.1253/jcj.62.791] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
A 15-year-old female with Ebstein's anomaly was referred to hospital for radiofrequency (RF) current catheter ablation of her refractory paroxysmal supraventricular tachycardia (PSVT) after tricuspid valve replacement. A surface ECG showed ventricular preexcitation of type B Wolff-Parkinson-White (WPW) syndrome. In a baseline electrophysiological study, two types of PSVT with left and right bundle branch block (LBBB and RBBB) configurations were induced. The LBBB type was antidromic and the RBBB type was orthodromic atrioventricular reciprocating tachycardia (AVRT) with a right posterolateral accessory pathway. RF current was successfully delivered at the posterolateral site above the prosthetic valve (V-delta interval = -30 msec). The patient has been free from arrhythmias during a follow-up period of 9 months. RF current ablation seems to be useful for AVRT patients with corrected Ebstein's anomaly.
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Affiliation(s)
- T Ai
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Japan
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Frey B, Kreiner G, Berger R, Gössinger HD. Unusual locations for adenosine-sensitive accessory atrioventricular pathways with decremental conduction. J Cardiovasc Electrophysiol 1998; 9:909-15. [PMID: 9786071 DOI: 10.1111/j.1540-8167.1998.tb00131.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Accessory AV pathways with decremental conduction are uncommon and, in particular, are thought not to occur at the anterior portion of the mitral annulus. METHODS AND RESULTS This report describes successful catheter ablation in three patients with accessory AV pathways that were adenosine sensitive and showed decremental conduction properties. The pathways were located at the anteroseptal, anteroparaseptal, and anterolateral aspects of the mitral annulus. CONCLUSION Accessory pathways with decremental conduction do occur anywhere around the mitral annulus, even in the area of fibrous continuity between the aortic leaflet of the mitral valve and the aortic valve itself.
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Affiliation(s)
- B Frey
- Department of Cardiology, University of Vienna, Wien, Austria
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Johnson CT, Brooks C, Jaramillo J, Mickelsen S, Kusumoto FM. A left free-wall, decrementally conducting, atrioventricular (Mahaim) fiber: diagnosis at electrophysiological study and radiofrequency catheter ablation guided by direct recording of a Mahaim potential. Pacing Clin Electrophysiol 1997; 20:2486-8. [PMID: 9358491 DOI: 10.1111/j.1540-8159.1997.tb06089.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
A 64-year-old female with Wolff-Parkinson-White syndrome and an ECG demonstrating a right posterolateral accessory pathway was referred for electrophysiological study. During electrophysiological testing two AV pathways were identified: a right posterolateral pathway that displayed conventional electrophysiological properties: and a left free-wall pathway that conducted only anterogradely and demonstrated decremental properties. Two separate wide complex tachycardias were induced that utilized the left free-wall pathway anterogradely and either the AV node or the right posterolateral accessory pathway retrogradely. A discrete electrical potential on the free wall of the mitral annulus was identified during tachycardia and was utilized to facilitate mapping and ablation.
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Affiliation(s)
- C T Johnson
- Division of Cardiology, Lovelace Medical Center, Albuquerque, New Mexico 87108, USA
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Tanaka K, Suzuki F, Hiejima K, Fujimura O. Quantitative analysis of concealed conduction into accessory atrioventricular pathways in Wolff-Parkinson-White syndrome. Pacing Clin Electrophysiol 1997; 20:1342-53. [PMID: 9170136 DOI: 10.1111/j.1540-8159.1997.tb06789.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: 02/04/2023]
Abstract
Concealed conduction is demonstrated to occur in an accessory AV pathway (AP). To test the hypothesis that anterograde and retrograde concealed conduction in the AP would have different characteristics, 35 consecutive patients with single APs were studied. The anterograde or retrograde ERP of the AP could be determined in 23 of those patients. Anterograde concealed conduction in the AP was assessed in the first 13 patients with retrograde AP conduction (6 APs with retrograde conduction only and 5 with both directions) (group A). Retrograde concealed conduction in the AP was evaluated in the remaining 10 patients with anterograde AP conduction (6 APs with anterograde conduction only and 4 with both directions) (group B). The concealed conduction in the AP was quantified by determining the ERP of the AP using a "probe" extrastimulus (Sp) introduced in the opposite chamber. The ERP was determined both during conventional extrastimulus (S1S2 method; ERPc) and during that with an Sp (S1SpS2 method; ERPp). The Sp was delivered before or after the last S1 with various S1Sp intervals. The ERPp was determined at each S1Sp interval. Three distinct patterns in concealed conduction in the AP were noted. In the first pattern, the ERPp was always shorter than the ERPc, whereas the reverse relation was noted in the second pattern. The third pattern showed a combination of the two. In group A, only the first pattern was noted. In group B, the first, second, and third patterns were noted in 4, 2, and 4 patients, respectively. The first pattern was noted only in septal APs and the second and third were seen only in left free-wall APs. The second pattern was seen in patients with retrograde AP conduction, whereas the third one was mainly noted in patients without retrograde AP conduction. These observations indicate that anterograde and retrograde concealed conduction in the AP have different characteristics. Shortening of the ERPp might be due to the "peeling back" phenomenon, and its lengthening might be caused by the presence of the inhomogeneous refractory periods of the AP.
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Affiliation(s)
- K Tanaka
- First Department of Internal Medicine, Tokyo Medical and Dental University, Japan
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Chen SA, Tai CT, Lee SH, Chiang CE, Wen ZC, Chiou CW, Ueng KC, Chen YJ, Yu WJ, Huang JL, Chang MS. Electrophysiologic characteristics and anatomical complexities of accessory atrioventricular pathways with successful ablation of anterograde and retrograde conduction at different sites. J Cardiovasc Electrophysiol 1996; 7:907-15. [PMID: 8894933 DOI: 10.1111/j.1540-8167.1996.tb00465.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Catheter ablation may eliminate anterograde and retrograde accessory pathway conduction at closely adjacent but anatomically discrete sites. However, the mechanisms of this discrepancy, the electrophysiologic and anatomical characteristics, and information about systematic study from a large patient population are not available. The purpose of this study was to investigate the electrophysiologic characteristics and anatomical complexities of the accessory pathway in which anterograde and retrograde conduction was successfully ablated at different sites. METHODS AND RESULTS Thirty-eight (10.9%) patients (19 men and 19 women; mean age 37 +/- 2.4 years) fulfilling the criteria of having separate ablation sites for anterograde and retrograde conduction were designated as group I, and the other 310 patients (215 men and 95 women; mean age 47 +/- 0.6 years) were designated as group II. The patients with right-sided free-wall pathways had the highest incidence (18.6%) of separate ablation sites. The anatomical distance between anterograde and retrograde directions (left anterior oblique view, 13 +/- 0.6 vs 8 +/- 0.9 mm, P < 0.01; right anterior oblique view, 17 +/- 0.6 vs 5 +/- 0.7 mm, P < 0.01), and incidence of conduction impairment in one direction after successful ablation of another direction (15% vs 78%, P < 0.05) differed significantly between left and right free-wall pathways. The mean distances obtained from left (7 +/- 0.4 vs 14 +/- 0.4 mm, P < 0.05) and right (7 +/- 1.1 vs 15 +/- 0.9 mm, P < 0.05) anterior oblique views were shorter in patients who had impairment of conduction properties than those in patients without impaired conduction after successful ablation of one direction. CONCLUSIONS This study showed that anatomical and functional dissociation of the accessory pathway into anterograde and retrograde components was possible. Further study on the relation between electrophysiologic and pathologic characteristics would be helpful to confirm these findings.
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Affiliation(s)
- S A Chen
- Department of Medicine, National Yang-Ming University, Taiwan, Republic of China
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Chen SA, Tai CT, Chiang CE, Lee SH, Wen ZC, Chiou CW, Ueng KC, Chen YJ, Yu WC, Huang JL, Chang MS. Electrophysiologic characteristics, electropharmacologic responses and radiofrequency ablation in patients with decremental accessory pathway. J Am Coll Cardiol 1996; 28:732-7. [PMID: 8772764 DOI: 10.1016/0735-1097(96)00219-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES This study sought to characterize the functional properties of decremental accessory atrioventricular (AV) pathways and to investigate their pharmacologic responses. BACKGROUND Although decremental AV pathways associated with incessant reciprocating tachycardia have been studied extensively, information about the electrophysiologic characteristics and pharmacologic responses of anterograde and retrograde decremental AV pathways is limited. METHODS Of 759 consecutive patients with accessory pathway-mediated tachyarrhythmia, 74 with decremental AV pathways were investigated (mean age 43 +/- 18 years). After baseline electrophysiologic study, the serial drugs adenosine, verapamil and procainamide were tested during atrial and ventricular pacing. Finally, radiofrequency catheter ablation was performed. RESULTS Five patients had anterograde decremental conduction over the accessory pathway but had no retrograde conduction. Of the 64 patients with retrograde decremental conduction over the accessory pathway, anterograde conduction over the pathway was absent in 41 (64%), intermittent in 5 (8%) and nondecremental in 18 (28%). In the remaining five patients, anterograde and retrograde decremental conduction over the same pathway was found. The anterograde and retrograde conduction properties and extent of decrement did not differ between anterograde and retrograde decremental pathways. Posteroseptal pathways had the highest incidences of anterograde and retrograde decremental conduction. Intravenous adenosine, procainamide and verapamil caused conduction delay or block, or both, in 10 of 10, 10 of 10 and 4 of 10 of the anterograde and 20 of 20, 20 of 20 and 8 of 20 of the retrograde decremental pathways, respectively. All patients had successful ablation of the decremental pathways without complications. During the follow-up period of 31 +/- 19 months, only one patient experienced recurrence. CONCLUSIONS Decremental accessory pathways usually had functionally distinct conduction characteristics in the anterograde and retrograde directions. Their pharmacologic responses suggested the heterogeneous mechanisms of decremental conduction.
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Affiliation(s)
- S A Chen
- Department of Medicine, National Yang-Ming University, Taipei, Taiwan, Republic of China
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Schoen WJ, Fujimura O. Variant preexcitation syndrome: a true nodoventricular mahaim fiber or an accessory atrioventricular pathway with decremental properties? J Cardiovasc Electrophysiol 1995; 6:1117-23. [PMID: 8720213 DOI: 10.1111/j.1540-8167.1995.tb00390.x] [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: 02/01/2023]
Abstract
INTRODUCTION The differentiation between a nodoventricular fiber and an accessory atrioventricular (AV) pathway with long conduction times and decremental properties could be very difficult even at detained electrophysiologic study. METHODS AND RESULTS A 20-year-old male with a history of a wide QRS tachycardia underwent electrophysiologic study. Baseline intervals were normal. There was evidence of dual AV pathways, and a sudden increase in AH interval was associated with the emergence of a delta wave. The atrio-delta interval showed a progressive prolongation. The preexcited QRS complex was typical of a posteroseptal pathway, and the earliest ventricular activation site was recorded at the posteroseptal region. Retrograde conduction was exclusively over the normal conduction system. During ventricular extrastimulation, a sudden increase in HA interval was associated with anterograde conduction over the accessory pathway. The intervals between the stimulus artifact and the onset of the delta wave during atrial pacing from two atrial sites (S-Delta) were compared with those between the retrograde atrial electrogram on the His channel and the onset of the delta wave during ventricular pacing (A2HB-Delta). When pacing from the proximal coronary sinus, the shortest S-Delta interval did become shorter than the longest A2HB-Delta interval (155 vs 170 msec). CONCLUSION The finding that the S-Delta interval could become shorter than the A2HB-Delta interval provides strong evidence that this accessory pathway was not connected to the AV node but arose directly from the atrial tissue of the posteroseptal region.
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Affiliation(s)
- W J Schoen
- Arrhythmia Service, University of Kentucky Medical Center, Lexington, USA
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Okishige K, Friedman PL. New observations on decremental atriofascicular and nodofascicular fibers: implications for catheter ablation. Pacing Clin Electrophysiol 1995; 18:986-98. [PMID: 7659572 DOI: 10.1111/j.1540-8159.1995.tb04739.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
INTRODUCTION The purpose of this study was to characterize the anatomy and physiology of accessory pathways that exhibit anterograde decremental conduction. RESULTS Among 100 consecutive patients with an accessory pathway undergoing electrophysiological study, six individuals with decremental anterograde accessory pathway conduction were identified. Anterograde accessory pathway effective refractory periods and conduction curves were assessed by atrial extrastimulus testing. Atrial pace mapping and ventricular activation sequence mapping were used to define accessory pathway origin and insertion. Surgical ablation (N = 1) or radiofrequency catheter ablation (N = 3) was performed based on accessory pathway anatomy as determined during electrophysiological study. Four of 6 patients had gaps in anterograde accessory pathway conduction. Two patients had evidence of functional longitudinal dissociation in the accessory pathway. Five of 6 patients had atriofascicular fibers with an atrial rather than AV nodal site of origin of their decrementally conducting accessory pathway and with distal insertions in the right bundle branch. Among these five patients, a right posterior atrial origin was nearly as common as a right anterior atrial origin. One patient had a true nodofascicular fiber that arose from the AV node, inserting distally into the left bundle branch. CONCLUSION Most accessory pathways with anterograde decremental conduction arise from the right anterior or right posterior atrium, not the AV node. A gap in anterograde accessory pathway conduction and functional longitudinal dissociation are common in such accessory pathways. Surgical or catheter ablation of such pathways is effective when directed at the atrial origin of the accessory pathway. True nodofascicular fibers arising from the AV node are rare. These may insert distally in the left ventricle. Catheter ablation of the proximal origin of such fibers is likely to result in complete AV block.
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Affiliation(s)
- K Okishige
- Cardiac Arrhythmia Service, Brigham and Women's Hospital, Boston, MA 02115
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Affiliation(s)
- L I Ganz
- Cardiac Arrhythmia Service, Brigham and Women's Hospital, Boston, MA 02115
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Goldberger JJ, Pederson DN, Damle RS, Kim YH, Kadish AH. Antidromic tachycardia utilizing decremental, latent accessory atrioventricular fibers: differentiation from adenosine-sensitive ventricular tachycardia. J Am Coll Cardiol 1994; 24:732-8. [PMID: 8077546 DOI: 10.1016/0735-1097(94)90022-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVES We studied two patients with latent, decremental atrioventricular (AV) fibers in whom pre-excitation could be demonstrated only during wide complex tachycardia. BACKGROUND The presence of decremental AV fibers participating in antidromic AV reentrant tachycardia is usually suspected by the presence of pre-excitation either in sinus rhythm or during atrial pacing. METHODS Two patients were referred for evaluation and treatment of wide complex tachycardia whose configuration suggested ventricular tachycardia that could be terminated with adenosine infusion. They underwent standard electrophysiologic studies. RESULTS Baseline AH and HV intervals were normal. No pre-excitation was noted with atrial overdrive at multiple sites or during atrial extrastimulation. Retrograde conduction was present with a sequence compatible with AV node conduction. Sustained wide complex tachycardia was induced with ventricular overdrive pacing. Late atrial premature depolarizations during tachycardia pre-excited the subsequent ventricular activation. Earlier atrial premature depolarizations delayed the subsequent ventricular activation. In one patient, early atrial premature depolarizations terminated the tachycardia without activating the ventricle. In the other patient, spontaneous tachycardia termination was accompanied by ventriculoatrial block. The earliest ventricular activation was at the annulus in the posteroseptal region in one patient and at the left posterior region in the other. Atrioventricular node reentry and atrial tachycardia with bystander AV fibers were also excluded. These findings establish the diagnosis of antidromic AV reentrant tachycardia utilizing a slow, decrementally conducting AV pathway. CONCLUSIONS This is the first report describing the presence of latent, decremental accessory AV pathways in which conduction was manifest only during antidromic AV reentrant tachycardia. To differentiate these wide complex tachycardias from adenosine-sensitive ventricular tachycardia, we recommend that atrial premature depolarizations be applied during tachycardia to rule out the presence of a latent, decremental AV fiber even in patients who do not otherwise have pre-excitation with atrial pacing techniques.
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Affiliation(s)
- J J Goldberger
- Department of Medicine, Northwestern University Medical School, Chicago, Illinois
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Müller G, Deal BJ, Benson DW. "Vagal maneuvers" and adenosine for termination of atrioventricular reentrant tachycardia. Am J Cardiol 1994; 74:500-3. [PMID: 8059736 DOI: 10.1016/0002-9149(94)90914-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- G Müller
- Division of Cardiology, Children's Memorial Hospital, Northwestern University, Chicago, Illinois 60614
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Interian A, Levin E, Castellanos A, Myerburg RJ. Mechanism of apparent incremental retrograde conduction across left lateral accessory pathways. Am J Cardiol 1994; 73:973-5. [PMID: 8184860 DOI: 10.1016/0002-9149(94)90146-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- A Interian
- Department of Medicine, University of Miami School of Medicine, Florida
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Abstract
In this review, we discuss the pathophysiology of the Wolff-Parkinson-White (WPW) syndrome and describe medical, surgical, and catheter based principles. WPW syndrome results from the congenital presence of impulse-conducting fascicles, known as accessory pathways (APs) or bypass tracts, which connect atria and ventricles across the annulus fibrosis and are capable of preexciting portions of the ventricular myocardium. Once triggered, atrioventricular reciprocating tachycardias (AVRTs) generally result from depolarization wavefronts moving anterograde through the AV node to the ventricles and returning retrograde to the atria along the AP. Rapid AVRT decreases ventricular filling time and cardiac output, resulting in symptoms. Medications that prolong AP refractory periods (flecainide, propafenone, and amiodarone) prevent rapid AP anterograde conduction (from atria to ventricles) in atrial tachycardias such as atrial fibrillation or flutter. In emergencies, adenosine can be used to terminate the AVRT of WPW syndrome. Otherwise, Class IA or IC antiarrhythmic agents are used to slow AP conduction either with or without AV nodal blocking agents. Open chest surgical ablation of a bypass tract in a symptomatic patient was first reported in 1968. The original endocardial surgical techniques for localizing and dividing APs were refined and an alternative epicardial approach has been developed. Reported mortality rates in experienced hands were 0% to 1.5% in large series for patients without additional cardiac abnormalities. Catheter delivered radiofrequency (RF) energy is now applied intravascularly to ablate APs. Since the first large series of patients undergoing RF ablation was reported in 1989, the procedure had proved safe, cost effective, and well tolerated. RF ablation has become the initial nonpharmacological treatment of choice for WPW syndrome; surgical ablation has become relegated to those cases where symptoms are intolerable and RF ablation is not feasible.
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Affiliation(s)
- T G Bartlett
- Cardiac Arrhythmia Service, Brigham and Women's Hospital, Boston, Massachusetts 02115
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Centurion OA, Fukatani M, Shimizu A, Konoe A, Isomoto S, Tanigawa M, Kaibara M, Yano K. Anterograde and retrograde decremental conduction over left-sided accessory atrioventricular pathways in the Wolff-Parkinson-White syndrome. Am Heart J 1993; 125:1038-47. [PMID: 8465726 DOI: 10.1016/0002-8703(93)90112-m] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The electrophysiologic properties of left-sided accessory pathways (APs) were examined by cardiac stimulation in 55 patients with Wolff-Parkinson-White syndrome. Atrioventricular and ventriculoatrial conduction times were assessed at the coronary sinus level nearest to the AP and then plotted graphically as a function of coupling interval (for atrial and ventricular refractory period determinations). Of 29 patients with anterograde conduction over the AP, 10 (34%) exhibited decremental conduction. However, only two (7%) had a maximal decrement equal to or more than 30 msec. In the other eight (27%) patients the maximal decrement ranged from 10 to 20 msec. The longest coupling interval at which anterograde decremental conduction was demonstrated ranged from 260 to 440 msec (346 +/- 52 msec). The shortest coupling interval ranged from 240 to 320 msec (265 +/- 24 msec). The anterograde decremental conduction zone was 91 +/- 55 msec. Of 51 patients with retrograde conduction over the AP, 23 (45%) exhibited decremental conduction. However, only eight (15%) had a maximal decrement equal to or greater than 30 msec. In the other 15 (29%) patients the maximal decrement ranged from 10 to 25 msec. The longest coupling interval was 338 +/- 70 msec. The shortest coupling interval was 275 +/- 42 msec. The retrograde decremental conduction zone was 72 +/- 47 msec. There was a significant inverse correlation between the AP effective refractory period and the maximal decrement (r = -0.42; p < 0.05). The comparison of maximal ventriculoatrial conduction time with the maximal decrement revealed a positive correlation (r = 0.63; p < 0.01). These data reveal that minimal decremental conduction over left-sided APs is not an uncommon finding and stress that care should be taken in evaluation of conduction over these connections.
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Affiliation(s)
- O A Centurion
- Third Department of Internal Medicine, Nagasaki University School of Medicine, Japan
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de Chillou C, Rodriguez LM, Schläpfer J, Kappos KG, Katsivas A, Baiyan X, Smeets JL, Wellens HJ. Clinical characteristics and electrophysiologic properties of atrioventricular accessory pathways: importance of the accessory pathway location. J Am Coll Cardiol 1992; 20:666-71. [PMID: 1512347 DOI: 10.1016/0735-1097(92)90022-f] [Citation(s) in RCA: 30] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVES This study was designed to assess the influence of accessory atrioventricular (AV) pathway location on the clinical and electrophysiologic characteristics of 384 consecutive symptomatic patients having a single accessory pathway. METHODS Four locations were studied: left free wall (n = 270), posteroseptal (n = 52), anteroseptal (n = 29) and right free wall (n = 33). Ten clinical variables and 12 electrophysiologic variables were analyzed, including the effective refractory period of the accessory pathway and the different clinically occurring and inducible arrhythmias. RESULTS Only two clinical findings were associated with accessory pathway location: 1) later age at onset of symptoms in the left free wall versus other accessory pathway locations (24 +/- 12 vs. 20 +/- 11 years, p = 0.02), and 2) later age at the time of electrophysiologic study in the left free wall accessory pathway location (36 +/- 13 vs. 32 +/- 11 years, p = 0.01). Six electrophysiologic variables showed a correlation with the accessory pathway location: 1) retrograde conduction only was found less frequently in right free wall (9%) and anteroseptal (10%) than in left free wall (26%) and posteroseptal (29%) accessory pathway locations (p = 0.05); 2) the retrograde effective refractory period of the accessory pathway was shorter in anteroseptal (253 +/- 52 ms) and left free wall (270 +/- 72 ms) as compared with right free wall (296 +/- 101 ms) and posteroseptal (301 +/- 76 ms) locations (p = 0.05); 3) retrograde decremental conduction over the accessory pathway was present in the posteroseptal (17%) and left free wall (3%) but absent in the other locations (p less than 0.001); 4) anterograde decremental conduction was only seen in the right free wall location (12%) (p less than 0.001); 5) orthodromic reentrant tachycardia was induced less frequently in the right free wall than in other locations (70% vs. 93%, p less than 0.001); and 6) inducibility of atrial fibrillation was greater in anteroseptal (62%) than in right free wall (21%), left free wall (44%) and posteroseptal (36%) locations (p = 0.01). CONCLUSIONS The location of the accessory AV pathway is associated with specific electrophysiologic characteristics.
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Affiliation(s)
- C de Chillou
- Department of Cardiology, University of Limburg Academic Hospital, Maastricht, The Netherlands
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