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Pambrun T, El Bouazzaoui R, Combes N, Combes S, Sousa P, Le Bloa M, Massoullié G, Cheniti G, Martin R, Pillois X, Duchateau J, Sacher F, Hocini M, Jaïs P, Derval N, Bortone A, Boveda S, Denis A, Haïssaguerre M, Albenque JP. Maximal Pre-Excitation Based Algorithm for Localization of Manifest Accessory Pathways in Adults. JACC Clin Electrophysiol 2018; 4:1052-1061. [DOI: 10.1016/j.jacep.2018.03.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 03/06/2018] [Accepted: 03/29/2018] [Indexed: 11/17/2022]
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Santilli RA, Santos LFN, Perego M. Permanent junctional reciprocating tachycardia in a dog. J Vet Cardiol 2013; 15:225-30. [PMID: 23962684 DOI: 10.1016/j.jvc.2013.06.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2012] [Revised: 05/07/2013] [Accepted: 06/07/2013] [Indexed: 11/19/2022]
Abstract
A 5-year-old male English Bulldog was presented with a 1-year history of paroxysmal supraventricular tachycardia (SVT) partially responsive to amiodarone. At admission the surface ECG showed sustained runs of a narrow QRS complex tachycardia, with a ventricular cycle length (R-R interval) of 260 ms, alternating with periods of sinus rhythm. Endocardial mapping identified the electrogenic mechanism of the SVT as a circus movement tachycardia with retrograde and decremental conduction along a concealed postero-septal atrioventricular pathway (AP) and anterograde conduction along the atrioventricular node. These characteristics were indicative of a permanent junctional reciprocating tachycardia (PJRT). Radiofrequency catheter ablation of the AP successfully terminated the PJRT, with no recurrence of tachycardia on Holter monitoring at 12 months follow-up.
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Affiliation(s)
- Roberto A Santilli
- Clinica Veterinaria Malpensa, Viale Marconi 27, 21017 Samarate, Varese, Italy.
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WITTKAMPF FREDH, VAN DRIEL VINCENTJ, VAN WESSEL HARRY, VINK ARYAN, HOF IRENEE, GRÜNDEMAN PAULF, HAUER RICHARDNW, LOH PETER. Feasibility of Electroporation for the Creation of Pulmonary Vein Ostial Lesions. J Cardiovasc Electrophysiol 2011; 22:302-9. [DOI: 10.1111/j.1540-8167.2010.01863.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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EL-CHAMI MIKHAELF, BLATT JACOB, LLOYD MICHAELS. A Diagnostic Response of a Supraventricular Tachycardia to a Ventricular Premature Beat. Pacing Clin Electrophysiol 2009; 32:660-2. [DOI: 10.1111/j.1540-8159.2009.02341.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Vaksmann G, D'Hoinne C, Lucet V, Guillaumont S, Lupoglazoff JM, Chantepie A, Denjoy I, Villain E, Marçon F. Permanent junctional reciprocating tachycardia in children: a multicentre study on clinical profile and outcome. Heart 2005; 92:101-4. [PMID: 15831598 PMCID: PMC1860982 DOI: 10.1136/hrt.2004.054163] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To investigate the clinical profile, natural history, and optimal management of persistent or permanent junctional reciprocating tachycardia (PJRT) in children. METHODS AND RESULTS 85 patients meeting the ECG criteria for PJRT were enrolled in a retrospective multicentre study. Age at diagnosis varied from birth to 20 years (median 3 months). Follow up ranged from 0.1 to 26.0 (median 8.2) years. At the time of referral, 24 of 85 patients (28%) had congestive heart failure that was resolved with medical treatment in all patients. Eighty three patients received drug treatment initially. Amiodarone and verapamil were the most effective with a success rate of 84-94% alone or in association with digoxin. Radiofrequency ablation of the accessory pathway was performed in 18 patients. There was a trend for a relation between age at ablation and the result of the procedure, failures being more common in younger patients (three of six procedures in younger and 15 of 18 in older children were successful; p = 0.14). Two patients with persistent left ventricular dysfunction on echocardiography but with no symptoms of congestive heart failure died suddenly one month and three years after diagnosis. PJRT resolved spontaneously in 19 patients (22%). Age at diagnosis of PJRT was not a predictor of spontaneous resolution. CONCLUSIONS PJRT is a potentially lethal arrhythmia in children with tachycardia induced cardiomyopathy. Spontaneous resolution of tachycardia is not uncommon. Antiarrhythmic treatment is often effective. Radiofrequency ablation should be performed in older children or when rate is not controlled, especially in patients with persistent left ventricular dysfunction.
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Affiliation(s)
- G Vaksmann
- Department of Paediatric Cardiology, Cardiological Hospital, Lille, France.
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Blaufox AD, Saul JP. Radiofrequency ablation of right-sided accessory pathways in pediatric patients. PROGRESS IN PEDIATRIC CARDIOLOGY 2001; 13:25-40. [PMID: 11413056 DOI: 10.1016/s1058-9813(01)00081-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Right free-wall and septal accessory pathways encompass the full spectrum of accessory pathway electrophysiology and are situated in complex anatomical arrangements. Understanding this diversity of physiology is necessary for the successful and safe elimination of these connections with transcatheter radiofrequency ablation. When radiofrequency catheter ablation of these pathways is attempted in children, anatomical relationships often become more complex, and spatial constraints require more adaptive techniques than in adults. It is clear that considerable progress has been made with radiofrequency catheter ablation, such that it is now first-line therapy for most children who have been diagnosed with one of the broad spectrum of clinical manifestations that result from the presence of these accessory connections. This review will discuss how accessory pathway electrophysiology and anatomy impact the clinical syndromes observed in children, and how these factors, as well as others particular to children, determine the approach, results and potential long-term consequences of radiofrequency catheter ablation of right-sided accessory pathways in the pediatric population.
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Affiliation(s)
- A D. Blaufox
- Medical University of South Carolina, Charleston, SC, USA
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Grimm W, Hoffmann J, Menz V, Maisch B. Transient QT prolongation with torsades de pointes tachycardia after ablation of permanent junctional reciprocating tachycardia. J Cardiovasc Electrophysiol 1999; 10:1631-5. [PMID: 10636193 DOI: 10.1111/j.1540-8167.1999.tb00227.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: 11/29/2022]
Abstract
INTRODUCTION Catheter ablation with radiofrequency energy is a curative therapy in patients with permanent junctional reciprocating tachycardia (PJRT). METHODS AND RESULTS For the first time, we report a case of transient QT prolongation with torsades de pointes tachycardia 18 hours after successful radiofrequency energy ablation of PJRT in a 25-year-old woman with tachycardia-induced cardiomyopathy. Of note, the torsades de pointes occurred in the absence of bradycardia, electrolyte disturbances, or QT-prolonging drugs. This patient initially was thought to have a hereditary long QT syndrome that was unmasked by PJRT ablation. Therefore, the patient received an implantable defibrillator in addition to beta-blocker therapy, which was discontinued 6 months later. Surprisingly, the QT interval completely normalized within 1 week after PJRT ablation, and the patient remained free of arrhythmias during a follow-up period of 4.5 years. CONCLUSION Patients with incessant tachyarrhythmias should undergo ECG monitoring for at least 24 hours following successful radiofrequency catheter ablation because transient QT prolongation with torsades de pointes may occur even in the absence of bradycardia, QT-prolonging drugs, or electrolyte disturbances.
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Affiliation(s)
- W Grimm
- Department of Medicine, Hospital of the Philipps-University of Marburg, Germany
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Chiang CE, Chen SA, Tai CT, Wu TJ, Lee SH, Cheng CC, Chiou CW, Ueng KC, Wen ZC, Chang MS. Prediction of successful ablation site of concealed posteroseptal accessory pathways by a novel algorithm using baseline electrophysiological parameters: implication for an abbreviated ablation procedure. Circulation 1996; 93:982-91. [PMID: 8598090 DOI: 10.1161/01.cir.93.5.982] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Radiofrequency catheter ablation of concealed posteroseptal accessory pathways (APS) has been a relatively difficult task for electrophysiologists. Without a detailed mapping procedure, the left versus the right posteroseptal AP could not be distinguished. We investigated the electrophysiological characteristics of concealed posteroseptal APs and defined criteria from baseline parameters to predict the successful ablation site. Validity of the criteria was prospectively verified. METHODS AND RESULTS Eighty-nine consecutive patients with a single concealed posteroseptal AP underwent successful radiofrequency catheter ablation. Of the initial 48 patients (group 1), the right posteroseptal area was first mapped. If no ideal electrogram could be obtained, or after several ineffective radiofrequency pulses, the left posteroseptal area was then mapped. Special attention was paid to the stability of the coronary sinus catheter with the most proximal electrode straddling the ostium, verified by coronary sinus venography, in all patients. Six patients (12.5%) had the earliest retrograde atrial activation at the middle electrode of the coronary sinus catheter, and successful ablation could only be achieved at the left posteroseptal area. For patients who presented with the earliest atrial activation at the proximal electrode, the presence of long RP' tachycardia suggested a right endocardial approach, while the delta VA (defined as the difference in the VA intervals between that recorded at the His bundle catheter and that at one of the electrode groups recording the earlier atrial activation) >-25 ms during tachycardia suggested a left endocardial approach. The subsequent 41 patients (group 2) were randomized into two subgroups. The initial mapping site was guided by the algorithm in group 2B, while it was not in group 2A. The successful ablation site could be predicted accurately in 18 (90%) of the 20 patients in group 2B. The radiofrequency pulses, ablation time, and fluoroscopic time were markedly reduced in Group 2B, mainly because of the omission of unnecessary mapping procedure in the right posteroseptal area in patients with "left atrio-left ventricular" fibers. CONCLUSIONS By the algorithm based on baseline electrophysiological parameters, the successful ablation site could be accurately predicted in a majority of patients with concealed posteroseptal APs. Radiofrequency pulses, ablation time, and fluoroscopic time were markedly reduced.
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Affiliation(s)
- C E Chiang
- Department of Medicine, National Yang-Ming University, School of Medicine, Taiwan, ROC
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Abstract
In recent years, the distinction between the diagnostic and therapeutic techniques used in the assessment and management of pediatric and adult patients with arrhythmias has gradually blurred. Nonetheless, arrhythmias in the pediatric patient are still often different from the adult patient in one of two important ways. First, a variety of arrhythmia mechanisms remain relatively unique to the pediatric population, some because of developmental issues and others because of early presentation of an incessant tachycardia. Second, the presentation and management of certain arrhythmias is sometimes markedly affected by patient age or the presence of structural congenital heart disease. A sampling from each of the above categories is reviewed and discussed.
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Affiliation(s)
- J P Saul
- Department of Cardiology, Children's Hospital, Harvard Medical School, Boston, MA, USA
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Gaita F, Haissaguerre M, Giustetto C, Fischer B, Riccardi R, Richiardi E, Scaglione M, Lamberti F, Warin JF. Catheter ablation of permanent junctional reciprocating tachycardia with radiofrequency current. J Am Coll Cardiol 1995; 25:648-54. [PMID: 7860909 DOI: 10.1016/0735-1097(94)00455-y] [Citation(s) in RCA: 74] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVES This study evaluated accessory pathway location, its relation to retrograde P wave polarity on the surface electrocardiogram and radiofrequency ablation efficacy and safety in a large group of patients with permanent junctional reciprocating tachycardia. BACKGROUND Permanent junctional reciprocating tachycardia is an uncommon form of reciprocating tachycardia, almost incessant from infancy and usually refractory to drug therapy. It is characterized by RP > PR interval and usually by negative P waves in leads II, III, aVF and V4 to V6. Retrograde conduction occurs through an accessory pathway with slow and decremental properties. Although this accessory pathway has been classically located in the posteroseptal zone, other locations have been recently reported. METHODS The study included 32 patients (20 men, 12 women, mean [+/- SD] age 29 +/- 15 years) with a diagnosis of permanent junctional reciprocating tachycardia confirmed at electrophysiologic study. Seven patients had depressed left ventricular function. Radiofrequency energy was applied at the site of the earliest retrograde atrial activation during tachycardia. RESULTS There were 33 accessory pathways. The site of the earliest retrograde atrial activation was posteroseptal in 25 patients (76%), midseptal in 4 (12%), right posterior in 1 (3%), right lateral in 1 (3%), left posterior in 1 (3%) and left lateral in 1 (3%). Thirty pathways were ablated with a right approach; in 11 patients with posteroseptal pathway the ablation was performed through the coronary sinus. Three pathways were ablated with a left approach. Positive retrograde P wave in lead I suggested that ablation could be performed from the right side; if negative, it did not exclude ablation from this approach. All the accessory pathways were successfully ablated, with a median of 3 and a mean of 5.6 +/- 5 radiofrequency applications of 70 +/- 26 s in duration. In two patients with the accessory pathway in the midseptal zone, a transient second- and third-degree atrioventricular block, respectively, was observed after ablation. At a mean follow-up of 18 +/- 12 months, 31 patients (97%) are asymptomatic without antiarrhythmic therapy (95% confidence interval [CI] 84% to 99%). Recurrences were observed in four patients (13%) (95% CI 4% to 29%), three of whom had the accessory pathway ablated successfully at a second session. All patients with depressed left ventricular function showed a marked improvement after successful ablation. CONCLUSIONS In our experience, most of the patients with permanent junctional reciprocating tachycardia had posteroseptal pathways; all these pathways were ablated from the right side. P wave configuration may be helpful in suggesting the approach to the site of ablation. Catheter ablation using radiofrequency energy is an effective therapy for permanent junctional reciprocating tachycardia.
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Affiliation(s)
- F Gaita
- Cardiology Department, Ospedale Civile of Asti, Italy
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Haïssaguerre M, Gaïta F, Marcus FI, Clémenty J. Radiofrequency catheter ablation of accessory pathways: a contemporary review. J Cardiovasc Electrophysiol 1994; 5:532-52. [PMID: 8087297 DOI: 10.1111/j.1540-8167.1994.tb01293.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Catheter ablation techniques are now advocated as the first line of therapy for arrhythmias caused by accessory pathways (APs). The most common energy source is radiofrequency current, but technical characteristics vary. Several parameters can be used to determine the optimal target site: AP potential, AV time, atrial or ventricular insertion site, or unipolar morphology. Specific considerations are needed depending on AP location. Despite the different approaches described, there is no significant difference in the reported success rate, which is over 90%. However, the number of radiofrequency applications needed to achieve ablation appears to differ significantly, with median values from 3 to 8 reported. A combination of criteria related to both timing and direction of the activation wavefront or use of subthreshold stimulation could improve the accuracy of mapping. In patients with "resistant" APs, different changes in ablation technique must be considered during the procedure to achieve elimination of AP conduction. The incidence of complications in multicenter reports is close to 4%, with a recurrence rate of 8%. The long-term safety of catheter ablation requires further study.
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Affiliation(s)
- M Haïssaguerre
- Hôpital Cardiologique du Haut-Leveque, Bordeaux-Pessac, France
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Shih HT, Miles WM, Klein LS, Hubbard JE, Zipes DP. Multiple accessory pathways in the permanent form of junctional reciprocating tachycardia. Am J Cardiol 1994; 73:361-7. [PMID: 8109550 DOI: 10.1016/0002-9149(94)90009-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The permanent form of junctional reciprocating tachycardia (PJRT) has been successfully eliminated by ablation of the accessory pathway responsible for the tachycardia. The coexistence of multiple accessory pathways responsible for different, long RP-interval tachycardias was not documented previously. Five patients with PJRT underwent radiofrequency catheter ablation of accessory pathways. Three of 5 patients had 2 accessory pathways each: 1 had 2 left free wall accessory pathways, another had a right posterior free wall and right posteroseptal pathway, whereas the third had 2 right posteroseptal pathways approximately 1 cm apart. The remaining 2 patients each had 1 right posteroseptal accessory pathway. Seven of 8 pathways were successfully ablated with a median of 3 radiofrequency pulses. No patient developed complications. Peak serum creatine kinase ranged from 131 to 311 IU/liter, with peak MB fraction 7 to 17 IU/liter, or 5 to 11%. Follow-up electrophysiologic study, 29 to 70 days after ablation, revealed no inducible tachycardia and no evidence of accessory pathway conduction, except for the 1 pathway not ablated. All patients remained asymptomatic 17 to 29 months after ablation. Thus, patients with PJRT can have several accessory pathways that can be safely and effectively eliminated with radiofrequency catheter ablation.
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Affiliation(s)
- H T Shih
- Department of Medicine and Pediatrics, Indiana University School of Medicine, Indianapolis
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Lemery R, Talajic M, Roy D, Lavoie L, Coutu B, Hii JT, Radzik D, Lavallee E, Cartier R. Results of a comparative study of low energy direct current with radiofrequency ablation in patients with the Wolff-Parkinson-White syndrome. BRITISH HEART JOURNAL 1993; 70:580-4. [PMID: 8280531 PMCID: PMC1025398 DOI: 10.1136/hrt.70.6.580] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To compare two new power sources for catheter ablation in patients with the Wolff-Parkinson-White syndrome. DESIGN 120 consecutive patients with accessory pathways had catheter ablation. Low energy direct current (DC) was used in the first 60 patients and radio-frequency current in the next 60 patients. SETTING Electrophysiological laboratory of a large heart institute. PATIENTS 72 men and 48 women (mean (SD) age 35 (14) years (range 9-75)). The accessory pathways were in the left free wall in 73 patients. They were posteroseptal in 35 patients, in the right free wall in five, and anteroseptal in seven. There was no significant difference in the clinical or electrophysiological variables between the two ablation groups. RESULTS Catheter ablation with low energy direct current was successful in 55/60 patients (92%) and radiofrequency energy was successful in 52/60 patients (87%). Low energy direct current was also successful in four of the eight patients in whom radiofrequency ablation had failed. Radiofrequency ablation was successful in two of the five patients in whom low energy direct current ablation had failed. The mean (SD) procedure and fluoroscopy times for successful ablation were 3.2 (1.5) h and 61 (40) min respectively. These times were similar for both power sources. Accessory pathway conduction recurred in 17 patients (28%) who had low energy direct current and four patients (7%) who received radiofrequency energy (p < 0.004). All patients with recurrence of an accessory pathway had successful re-ablation. CONCLUSIONS Both new power sources successfully ablated accessory pathways, (overall success rate 94% (113/120 patients)). Radiofrequency ablation, however, did not require general anaesthesia and was associated with a significantly lower rate of recurrence of accessory pathway conduction. Therefore radiofrequency should be used initially for ablation. Low energy direct current may be most useful as a back-up in patients in whom radiofrequency ablation fails.
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Affiliation(s)
- R Lemery
- Department of Medicine, Montreal Heart Institute, Canada
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Ticho BS, Saul JP, Hulse JE, De W, Lulu J, Walsh EP. Variable location of accessory pathways associated with the permanent form of junctional reciprocating tachycardia and confirmation with radiofrequency ablation. Am J Cardiol 1992; 70:1559-64. [PMID: 1466323 DOI: 10.1016/0002-9149(92)90457-a] [Citation(s) in RCA: 69] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Permanent junctional reciprocating tachycardia (PJRT) occurs primarily in young patients and causes nearly incessant tachycardia that is frequently refractory to pharmacologic treatment. Previous nonpharmacologic therapy has included surgical or direct-current catheter ablation of either the His bundle or the accessory pathway. The accessory pathway in PJRT has been described as having retrograde and anterograde decremental conduction properties, and is typically identified in the posteroseptal location. This report describes radiofrequency catheter ablation of accessory pathways in 8 patients with PJRT. All ablations were successful and without adverse effects. Accessory pathway potentials were detected just before atrial activation in 6 of 8 patients. A new finding was that 5 of the 8 pathway locations, as identified by the site of successful ablation, were not in the typical posteroseptal region. In 1 patient it was located in the right posteroseptal region, 2 were in the right atrial freewall, 1 was in the right anterior septum and 1 was in the left posterior region just outside of the septal region. In conclusion, radiofrequency catheter ablation can be a highly effective and safe method for treatment of young patients with PJRT. Because the accessory pathways can be located outside of the posteroseptal region, careful mapping of both the right and left atrioventricular groove may be necessary for successful ablation.
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Affiliation(s)
- B S Ticho
- Department of Cardiology, Children's Hospital, Boston, Massachusetts 02115
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