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Katritsis DG, Fragakis N, Katritsis G, Doukas V, Marine JE, Desmukh A, Latchamsetty R, Anderson RH, Calkins H. High-resolution mapping of the circuit of typical atrioventricular nodal reentrant tachycardia. J Interv Card Electrophysiol 2024; 67:599-607. [PMID: 37691082 DOI: 10.1007/s10840-023-01632-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 08/30/2023] [Indexed: 09/12/2023]
Abstract
BACKGROUND Recent anatomic and electrophysiologic evidence has provided new insight into the anatomic substrate. Previous reports on electroanatomic mapping (EAM) of the circuit of atrioventricular nodal reentrant tachycardia (AVNRT) have been limited by mapping only the triangle of Koch on the right side of the septum and by the use of conventional mapping tools. The objectives are to obtain comprehensive high-resolution mapping of typical AVNRT and to investigate the role of the atrioventricular ring tissues in the circuit. METHODS We employed EAM with the use of novel modules and algorithms for studying typical AVNRT from the right and the left sides of the septum. RESULTS We performed extensive mapping of both the atrial septum and the septal vestibule of the tricuspid valve during typical AVNRT in 9 (6 females) patients, aged 49.6 ± 12.1 years. In two of these, left septal mapping was also obtained through the aorta. The earliest initial activation was variable, emanating from the superior or medial septum. The impulse consistently appeared below the orifice of the coronary sinus, at the site where its inferoanterior margin merged with the septal vestibule of the tricuspid valve at its entrance to the right atrium. It then returned to the initial activation site, presumably through the septal vestibular myocardium. The left septal activation area corresponded to that recorded on the right side. CONCLUSIONS Typical AVNRT uses a circuit confined within the pyramid of Koch from the AV node to the septal isthmus, involving the myocardial walls of the pyramidal space.
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Affiliation(s)
- Demosthenes G Katritsis
- Hygeia Hospital, 4 Erythrou Stavrou Str, 15123, Athens, Greece.
- Johns Hopkins Hospital, Baltimore, MD, USA.
| | | | | | | | | | - Amrish Desmukh
- University of Michigan Medical School, Ann Arbor, MI, USA
| | | | - Robert H Anderson
- Biosciences Institute, Newcastle University, Newcastle Upon Tyne, UK
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2
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Park S, Park JW, Kim S, Kim H, Kim SH, Oh YS, Choi Y. Upper common pathway analysis using late atrial premature depolarization in atrioventricular nodal reentry tachycardia. Heart Rhythm 2024:S1547-5271(24)02283-5. [PMID: 38552730 DOI: 10.1016/j.hrthm.2024.03.1788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 03/21/2024] [Accepted: 03/25/2024] [Indexed: 04/18/2024]
Abstract
BACKGROUND Anatomic and electrophysiologic findings suggest that the actual circuit of atrioventricular nodal reentrant tachycardia (AVNRT) involves the perinodal atrium. However, occasional instances in which the atrium is dissociated from the AVNRT have led to the concept of an upper common pathway (UCP). OBJECTIVE We aimed to assess the prevalence of UCP in AVNRT using a late atrial premature depolarization (LAPD) maneuver. METHODS Patients who were diagnosed with typical AVNRT by electrophysiologic studies were enrolled. For evaluation of the presence of UCP, an LAPD was given at the coronary sinus ostium (osCS) during AVNRT, and then pacing was repeated incrementally every 10 ms. Electrograms in the earliest retrograde atrial activation site (ERAS) near the proximal His were mapped and recorded during the pacing. Results were interpreted as follows: absence of UCP-an LAPD from the osCS can reset the tachycardia without depolarizing the ERAS; presence of UCP-an LAPD from the osCS can depolarize the ERAS without resetting the tachycardia; and indeterminate-an LAPD from the osCS either resets the ERAS and tachycardia simultaneously or does not reset both. RESULTS The LAPD maneuver was performed in 126 patients with AVNRT. It demonstrated an absence of UCP in 121 (96.0%) patients and the presence of UCP in 3 (2.4%) patients; the result was indeterminate in 2 (1.6%) patients. CONCLUSION The LAPD maneuver revealed that the presence of UCP is indicated in only rare cases of AVNRT. In most AVNRT cases, the atrium is involved in the reentry circuit.
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Affiliation(s)
- Soyoon Park
- Division of Cardiology, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Cardiovascular Research Institute for Intractable Disease, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jeong-Wook Park
- Division of Cardiology, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Soohyun Kim
- Division of Cardiology, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Cardiovascular Research Institute for Intractable Disease, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hwajung Kim
- Cardiovascular Research Institute for Intractable Disease, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Division of Cardiology, Department of Internal Medicine, Yeouido St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sung-Hwan Kim
- Division of Cardiology, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Cardiovascular Research Institute for Intractable Disease, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yong-Seog Oh
- Division of Cardiology, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Cardiovascular Research Institute for Intractable Disease, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Young Choi
- Division of Cardiology, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Cardiovascular Research Institute for Intractable Disease, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
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3
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Pandozi C, Matteucci A, Galeazzi M, Russo M, Lavalle C, Ficili S, Malacrida M, Colivicchi F. New insights into atrioventricular nodal anatomy, physiology, and immunochemistry: A comprehensive review and a proposed model of the slow-fast atrioventricular nodal reentrant tachycardia circuit in agreement with direct potential recordings in the Koch's triangle area. Heart Rhythm 2023; 20:614-626. [PMID: 36634901 DOI: 10.1016/j.hrthm.2023.01.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 01/04/2023] [Accepted: 01/04/2023] [Indexed: 01/11/2023]
Abstract
Atrioventricular nodal reentrant tachycardia (AVNRT) is the most frequent regular tachycardia in humans. In this review, we describe the most recent discoveries regarding the anatomical, physiological, and molecular biological features of the atrioventricular junction that could underlie the typical slow-fast AVNRT mechanisms, as these insights could lead to the proposal of a new theory concerning the circuit of this arrhythmia. Despite several models have been proposed over the years, the precise anatomical site of the reentrant circuit and the pathway involved in the slow-fast AVNRT have not been conclusively defined. One possible way to evaluate all the hypotheses regarding the nodal tachycardia circuit in humans is to map this circuit. Thus, we tried to identify the slow potential of nodal and inferior extension structures by using automated mapping of atrial activation during both sinus rhythm and typical slow-fast AVNRT. This constitutes a first step toward the definition of nodal area activation in sinus rhythm and during slow-fast AVNRT. Further studies and technical improvements in recording the potentials of the atrioventricular node structures are necessary to confirm our initial results.
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Affiliation(s)
- Claudio Pandozi
- Division of Cardiology, San Filippo Neri Hospital, Rome, Italy.
| | | | - Marco Galeazzi
- Division of Cardiology, San Filippo Neri Hospital, Rome, Italy
| | - Maurizio Russo
- Division of Cardiology, San Filippo Neri Hospital, Rome, Italy
| | - Carlo Lavalle
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, "Sapienza" University of Rome, Rome, Italy
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4
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Hasebe H, Furuyashiki Y, Yoshida K, Fujiki A, Nogami A. Diastolic potentials manifest the extension of a slow pathway to the inferolateral right atrium during fast-slow atrioventricular nodal reentrant tachycardia. HeartRhythm Case Rep 2022; 9:91-96. [PMID: 36860746 PMCID: PMC9968910 DOI: 10.1016/j.hrcr.2022.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Hideyuki Hasebe
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan,Division of Arrhythmology, Shizuoka Saiseikai General Hospital, Shizuoka, Japan,Address reprint requests and correspondence: Dr Hideyuki Hasebe, Division of Arrhythmology, Shizuoka Saiseikai General Hospital, 1-1-1 Oshika, Suruga-ku, Shizuoka 422-8527, Japan.
| | | | - Kentaro Yoshida
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | | | - Akihiko Nogami
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
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5
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Quantitative assessment of the fast pathway in atrioventricular nodal reentrant tachycardia. J Interv Card Electrophysiol 2022; 66:991-996. [PMID: 36355272 DOI: 10.1007/s10840-022-01408-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 10/26/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Mathematical modelling has allowed calculation of the length of the slow and fast pathways in typical atrioventricular nodal reentrant tachycardia (AVNRT). The length of the slow pathway has been correlated with the measured length of the right inferior extension in human histologic specimens, but no histology data exist about the fast pathway. METHODS In preparations of cadaveric human hearts, the AV node was identified, and the site of the fast pathway was projected according to both existing evidence and results of our electroanatomic mapping. This permitted measurement of the length of the fast pathway as a limb of the tachycardia circuit. RESULTS Measurements of the length of the projected area of the fast pathway on histology specimens were performed in 8 hearts. The estimated length of the fast pathway was 39.6 ± 5.8 mm (range: 30.4-45.9 mm). These numbers are comparable to those produced by mathematical calculations of the length of the fast pathway. CONCLUSIONS Typical AVNRT uses a circuit from the AV node to the septal isthmus of an average size of 5-6 cm, confined within the pyramid of Koch.
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6
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Katritsis DG, Anderson RH. New Insights Into the Mechanisms of Fast and Slow Conduction in the Atrioventricular Node. Heart Rhythm 2022; 20:627-630. [PMID: 36049588 DOI: 10.1016/j.hrthm.2022.08.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 08/15/2022] [Accepted: 08/17/2022] [Indexed: 11/17/2022]
Affiliation(s)
| | - Robert H Anderson
- Biosciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
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7
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Waldmann V, Hebe J, Walsh EP, Khairy P, Ernst S. Catheter Ablation of Atrioventricular Nodal Reentrant Tachycardia in Patients With Congenital Heart Disease. Circ Arrhythm Electrophysiol 2022; 15:e010631. [PMID: 35089803 DOI: 10.1161/circep.121.010631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Atrioventricular (AV) nodal reentrant tachycardia represents the most common regular supraventricular arrhythmia in humans, and catheter ablation of the so called slow AV nodal pathway has been effectively performed for decades. In patients with congenital heart disease, a combination of different factors makes catheter ablation of AV nodal reentrant tachycardia substrate particularly challenging, including abnormal venous access to intracardiac structures, abnormal intracardiac anatomy, potentially deviant and often unpredictable sites of the specific conduction system, loss of traditional anatomic landmarks, and congenital cardiac surgery that may complicate the access to the AV nodal area. Published experiences have confirmed the efficacy and the relative safety of such procedures when performed by experts, but the risk of complications, in particular AV block, remains non-negligible. A thorough knowledge and understanding of anatomic and electrical specificities according to underlying phenotype are essential in addressing these complex cases. Considering the major consequences associated with AV block in patients with complex congenital heart disease, particularly those without low risk access for transvenous ventricular pacing (eg, single ventricle physiology or Eisenmenger syndrome), the individual risk-benefit ratio should be carefully evaluated. The decision to defer ablation may be the wisest approach in selected patients with either infrequent or hemodynamically tolerated arrhythmias, or when the location of the AV conduction pathways remains uncertain. This narrative review aims to synthetize existing literature on catheter ablation of AV nodal reentrant tachycardia in congenital heart disease, to present main features of common associated pathologies, and to discuss approaches to mapping and safely ablating the slow AV nodal pathway in challenging cases.
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Affiliation(s)
- Victor Waldmann
- Electrophysiology and Adult Congenital Heart Disease Medico-Surgical Unit, European Georges Pompidou Hospital, Paris, France (V.W.).,Pediatric and Congenital Heart Disease Department, Necker Hospital, Paris, France (V.W.)
| | - Joachim Hebe
- Center for Electrophysiology Bremen at Heart Center Bremen, Germany (J.H.)
| | - Edward P Walsh
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, MA (E.P.W.)
| | - Paul Khairy
- Electrophysiology Service and Adult Congenital Heart Center, Montreal Heart Institute, Université de Montréal, Quebec, Canada (P.K.)
| | - Sabine Ernst
- Royal Brompton Hospital, Guys and St. Thomas' NHS Foundation Trust, London, United Kingdom (S.E.).,National Heart and Lung Institute, Imperial College, London, United Kingdom (S.E.)
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Tretter JT, Spicer DE, Sánchez-Quintana D, Back Sternick E, Farré J, Anderson RH. Miniseries 1-Part III: 'Behind the scenes' in the triangle of Koch. Europace 2022; 24:455-463. [PMID: 34999775 DOI: 10.1093/europace/euab285] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 11/02/2021] [Indexed: 11/14/2022] Open
Abstract
AIMS To take full advantage of the knowledge of cardiac anatomy, structures should be considered in their correct attitudinal orientation. Our aim was to discuss the triangle of Koch in an attitudinally appropriate fashion. METHODS AND RESULTS We reviewed our material prepared by histological sectioning, along with computed tomographic datasets of human hearts. The triangle of Koch is the right atrial surface of the inferior pyramidal space, being bordered by the tendon of Todaro and the hinge of the septal leaflet of the tricuspid valve, with its base at the inferior cavotricuspid isthmus. The fibro-adipose tissues of the inferior pyramidal space separate the atrial wall from the crest of the muscular interventricular septum, thus producing an atrioventricular muscular sandwich. The overall area is better approached as a pyramid rather than a triangle. The apex of the inferior pyramidal space overlaps the infero-septal recess of the subaortic outflow tract, permitting the atrioventricular conduction axis to transition directly to the crest of the muscular ventricular septum. The compact atrioventricular node is formed at the apex of the pyramid by union of its inferior extensions, which represent the slow pathway, with the septal components formed in the buttress of the atrial septum, thus providing the fast pathway. CONCLUSIONS To understand its various implications in current cardiological catheter interventions, the triangle of Koch must be considered in conjunction with the inferior pyramidal space and the infero-septal recess. It is better to consider the overall region in terms of a pyramidal area of interest.
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Affiliation(s)
- Justin T Tretter
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Diane E Spicer
- Department of Pediatric Cardiology, University of Florida, Gainesville, FL, USA
| | | | | | - Jerónimo Farré
- Fundación Jiménez Díaz University Hospital and Institute of Biomedical Research, Madrid, Spain
| | - Robert H Anderson
- Institute of Biosciences, Newcastle University, Newcastle upon Tyne, UK
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9
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Sánchez-Quintana D, Anderson RH, Tretter JT, Cabrera JA, Sternick EB, Farré J. Anatomy of the conduction tissues 100 years on: what have we learned? Heart 2021; 108:1430-1437. [PMID: 34969873 DOI: 10.1136/heartjnl-2021-320304] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 11/30/2021] [Indexed: 11/04/2022] Open
Abstract
Knowledge of the anatomy of the 'conduction tissues' of the heart is a 20th century phenomenon. Although controversies still continue on the topic, most could have been avoided had greater attention been paid to the original descriptions. All cardiomyocytes, of course, have the capacity to conduct the cardiac impulse. The tissues specifically described as 'conducting' first generate the cardiac impulse, and then deliver it in such a fashion that the ventricles contract in orderly fashion. The tissues cannot readily be distinguished by gross inspection. Robust definitions for their recognition had been provided by the end of the first decade of the 20th century. These definitions retain their currency. The sinus node lies as a cigar-shaped structure subepicardially within the terminal groove. There is evidence that it is associated with a paranodal area that may have functional significance. Suggestions of dual nodes, however, are without histological confirmation. The atrioventricular node is located within the triangle of Koch, with significant inferior extensions occupying the atrial vestibules and with septal connections. The conduction axis penetrates the insulating plane of the atrioventricular junctions to continue as the ventricular pathways. Remnants of a ring of cardiomyocytes observed during development are also to be found within the atrial vestibules, particularly a prominent retroaortic remnant, although that their role has still to be determined. Application of the initial criteria for nodes and tracts shows that there are no special 'conducting tissues' in the pulmonary venous sleeves that might underscore the abnormal rhythm of atrial fibrillation.
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Affiliation(s)
| | - Robert H Anderson
- Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Justin T Tretter
- Heart Institute, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - José Angel Cabrera
- Department of Cardiology, Hospital Universitario Quirón-Madrid, European University of Madrid, Madrid, Spain
| | | | - Jerónimo Farré
- Madrid Autonomous University, Fundación Jiménez Díaz Hospital, Madrid, Spain
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10
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Anderson RH, Hikspoors JPJM, Tretter JT, Mac�as Y, Spicer DE, Lamers WH, S�nchez-Quintana D, Sternick EB. Inferior Extensions of the Atrioventricular Node. Arrhythm Electrophysiol Rev 2021; 10:262-272. [PMID: 35106179 PMCID: PMC8785076 DOI: 10.15420/aer.2021.43] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 09/02/2021] [Indexed: 12/29/2022] Open
Abstract
The pathways for excitation of the atrioventricular node enter either superiorly, as the so-called ‘fast’ pathway, or inferiorly as the ‘slow’ pathway. However, knowledge of the specific anatomical details of these pathways is limited. Most of the experimental studies that established the existence of these pathways were conducted in mammalian hearts, which have subtle differences to human hearts. In this review, the authors summarise their recent experiences investigating human cardiac development, correlating these results with the arrangement of the connections between the atrial myocardium and the compact atrioventricular node as revealed by serial sectioning of adult human hearts. They discuss the contributions made from the atrioventricular canal myocardium, as opposed to the primary ring. Both these rings are incorporated into the atrial vestibules, albeit with the primary ring contributing only to the tricuspid vestibule. The atrial septal cardiomyocytes are relatively late contributors to the nodal inputs. Finally, they relate our findings of human cardiac development to the postnatal arrangement.
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Affiliation(s)
- Robert H Anderson
- Biosciences Institute, Newcastle University, Newcastle-upon-Tyne, UK
| | - Jill PJM Hikspoors
- Department of Anatomy and Embryology, Maastricht University, Maastricht, the Netherlands
| | - Justin T Tretter
- Heart Institute, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, US
| | - Yolanda Mac�as
- Department of Human Anatomy and Cell Biology, Faculty of Medicine, University of Extremadura, Badajoz, Spain
| | - Diane E Spicer
- Congenital Heart Center, University of Florida, Gainesville, FL, US
- Heart Institute, Johns Hopkins All Children’s Hospital, St Petersburg, FL, US
| | - Wouter H Lamers
- Department of Anatomy and Embryology, Maastricht University, Maastricht, the Netherlands
| | - Dami�n S�nchez-Quintana
- Department of Human Anatomy and Cell Biology, Faculty of Medicine, University of Extremadura, Badajoz, Spain
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11
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Katritsis DG, Calkins H, Anderson RH. The Specialized Atrioventricular Ring Tissues Participate in the Circuit of Atrioventricular Nodal Reentrant Tachycardia. J Am Heart Assoc 2021; 10:e022811. [PMID: 34719243 PMCID: PMC8751966 DOI: 10.1161/jaha.121.022811] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | - Robert H Anderson
- Biosciences Institute Newcastle University Newcastle upon Tyne United Kingdom
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12
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Katritsis DG, Marine JE, Katritsis G, Latchamsetty R, Zografos T, Zimetbaum P, Buxton AE, Calkins H, Morady F, Sánchez-Quintana D, Anderson RH. Spatial characterization of the tachycardia circuit of atrioventricular nodal re-entrant tachycardia. Europace 2021; 23:1596-1602. [PMID: 34240123 DOI: 10.1093/europace/euab130] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 05/04/2021] [Indexed: 11/13/2022] Open
Abstract
AIMS The exact circuit of atrioventricular nodal re-entrant tachycardia (AVNRT) remains elusive. To assess the location and dimensions of the AVNRT circuit. METHODS AND RESULTS Both typical and atypical AVNRT were induced at electrophysiology study of 14 patients. We calculated the activation time of the fast and slow pathways, and consequently, the length of the slow pathway, by assuming an average conduction velocity of 0.04 mm/ms in the nodal area. The distance between the compact atrioventricular node and the slow pathway ablating electrode was measured on three-dimensionally reconstructed fluoroscopic images obtained in diastole and systole. We also measured the length of the histologically discrete right inferior nodal extension in 31 human hearts. The length of the slow pathway was calculated to be 10.8 ± 1.3 mm (range 8.2-12.8 mm). The distance from the node to the ablating electrode was measured in five patients 17.0 ± 1.6 mm (range 14.9-19.2 mm) and was consistently longer than the estimated length of the slow pathway (P < 0.001). The length of the right nodal inferior extension in histologic specimens was 8.1 ± 2.3 mm (range 5.3-13.7 mm). There were no statistically significant differences between these values and the calculated slow pathway lengths. CONCLUSION Successful ablation affects the tachycardia circuit without necessarily abolishing slow conduction, probably by interrupting the circuit at the septal isthmus.
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Affiliation(s)
- Demosthenes G Katritsis
- Hygeia Hospital, 4 Erythrou Stavrou Str, Athens 15123, Greece.,Johns Hopkins Hospital, Baltimore, MD, USA
| | | | | | | | | | - Peter Zimetbaum
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Alfred E Buxton
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | | | - Damián Sánchez-Quintana
- Department of Anatomy and Cell Biology, Faculty of Medicine, University of Extremadura, Badajoz, Spain
| | - Robert H Anderson
- Biosciences Institute, Newcastle University, Newcastle upon Tyne, UK
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13
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Calderón-Garcidueñas L, González-Maciel A, Reynoso-Robles R, Rodríguez-López JL, Silva-Pereyra HG, Labrada-Delgado GJ, Pérez-Guillé B, Soriano-Rosales RE, Jiménez-Bravo Luna MA, Brito-Aguilar R, Mukherjee PS, Gayosso-Chávez C, Delgado-Chávez R. Environmental Fe, Ti, Al, Cu, Hg, Bi, and Si Nanoparticles in the Atrioventricular Conduction Axis and the Associated Ultrastructural Damage in Young Urbanites: Cardiac Arrhythmias Caused by Anthropogenic, Industrial, E-Waste, and Indoor Nanoparticles. ENVIRONMENTAL SCIENCE & TECHNOLOGY 2021; 55:8203-8214. [PMID: 34081443 DOI: 10.1021/acs.est.1c01733] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Air pollution exposure is a risk factor for arrhythmia. The atrioventricular (AV) conduction axis is key for the passage of electrical signals to ventricles. We investigated whether environmental nanoparticles (NPs) reach the AV axis and whether they are associated with ultrastructural cell damage. Here, we demonstrate the detection of the shape, size, and composition of NPs by transmission electron microscopy (TEM) and energy-dispersive X-ray spectrometry (EDX) in 10 subjects from Metropolitan Mexico City (MMC) with a mean age of 25.3 ± 5.9 and a 71-year-old subject without cardiac pathology. We found that in every case, Fe, Ti, Al, Hg, Cu, Bi, and/or Si spherical or acicular NPs with a mean size of 36 ± 17 nm were present in the AV axis in situ, freely and as conglomerates, within the mitochondria, sarcomeres, lysosomes, lipofuscin, and/or intercalated disks and gap junctions of Purkinje and transitional cells, telocytes, macrophages, endothelium, and adjacent atrial and ventricular fibers. Erythrocytes were found to transfer NPs to the endothelium. Purkinje fibers with increased lysosomal activity and totally disordered myofilaments and fragmented Z-disks exhibited NP conglomerates in association with gap junctions and intercalated disks. AV conduction axis pathology caused by environmental NPs is a plausible and modifiable risk factor for understanding common arrhythmias and reentrant tachycardia. Anthropogenic, industrial, e-waste, and indoor NPs reach pacemaker regions, thereby increasing potential mechanisms that disrupt the electrical impulse pathways of the heart. The cardiotoxic, oxidative, and abnormal electric performance effects of NPs in pacemaker locations warrant extensive research. Cardiac arrhythmias associated with nanoparticle effects could be preventable.
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Affiliation(s)
- Lilian Calderón-Garcidueñas
- The University of Montana, 32 Campus Drive, 287 Skaggs Building, Missoula, Montana 59812, United States
- Universidad del Valle de México, Ciudad de México 14370, México
| | | | | | | | - Hector G Silva-Pereyra
- Instituto Potosino de Investigación Científica y Tecnológica A. C., San Luis Potosí 78216, México
| | - Gladis J Labrada-Delgado
- Instituto Potosino de Investigación Científica y Tecnológica A. C., San Luis Potosí 78216, México
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14
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Catheter ablation via the left atrium for atrioventricular nodal reentrant tachycardia: A narrative review. Heart Rhythm O2 2021; 2:187-200. [PMID: 34113921 PMCID: PMC8183875 DOI: 10.1016/j.hroo.2021.01.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Since 1996, it has been recognized that catheter ablation for atrioventricular nodal reentrant tachycardia (AVNRT) may require an approach through the left atrium. Objective The purposes are to present a case report and to provide a comprehensive narrative review on this topic. Methods A literature review of all articles that provided detailed information on patients who underwent catheter ablation via the left atrium for AVNRT was performed. The primary search queried PubMed using Medical Subject Headings (MeSH) terms "atrioventricular nodal reentrant tachycardia" and "left." The secondary search was performed by manual review of reference lists and Google Scholar citations of manuscripts retrieved by the primary search. The review was limited to the English language. Results The searches yielded 30 articles that described 79 patients. A case report was added. Therefore, the final review consisted of 80 patients. The prevalence of left atrial ablation for patients with AVNRT undergoing catheter ablation at tertiary care centers was approximately 1%. Failed right atrial ablation, with or without coronary sinus ablation, was the most common indication for left atrial ablation. Pooled data from 3 cohort studies estimated the acute success rate for radiofrequency ablation of the slow pathway at the septal or inferoparaseptal segments of the mitral valve annulus after failed right-sided ablation to be 90%. There were no reports of atrioventricular block requiring permanent pacemaker implantation. Conclusion Catheter ablation of the slow pathway via the left atrium is an important technique for AVNRT cases that are refractory to conventional ablation.
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Korkmaz A, Kara M, Deveci B, Sertdemir AL, Ozeke O, Cay S, Ozcan F, Topaloglu S, Aras D. Change in the atrial activation timing and sequence during narrow QRS tachycardia: What is the mechanism? J Cardiovasc Electrophysiol 2020; 32:148-150. [PMID: 33205575 DOI: 10.1111/jce.14813] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 11/03/2020] [Accepted: 11/09/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Ahmet Korkmaz
- Department of Cardiology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Meryem Kara
- Department of Cardiology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Bulent Deveci
- Department of Cardiology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Ahmet L Sertdemir
- Department of Cardiology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey.,Department of Cardiology, Meram Medical Faculty, Necmettin Erbakan University, Konya, Turkey
| | - Ozcan Ozeke
- Department of Cardiology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Serkan Cay
- Department of Cardiology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Firat Ozcan
- Department of Cardiology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Serkan Topaloglu
- Department of Cardiology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Dursun Aras
- Department of Cardiology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
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