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Gormel S, Yasar S, Yildirim E, Asil S, Baris VO, Gokoglan Y, Celik M, Yuksel UC, Vurgun VK, Kabul HK, Kose S. Comprehensive assessment of Mahaim accessory pathways' anatomic distribution. J Int Med Res 2022; 50:3000605211069751. [PMID: 35001697 PMCID: PMC8753247 DOI: 10.1177/03000605211069751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Objective To present the authors’ experience of Mahaim-type accessory pathways (MAPs), focusing on anatomic localizations. Methods Data from consecutive patients who underwent electrophysiological study (EPS) for MAP ablation in two tertiary centres, between January 1998 and June 2020, were retrospectively analysed. Results Of the 55 included patients, 27 (49.1%) were male, and the overall mean age was 29.5 ± 11.6 years (range, 12–66 years). MAPs were ablated at the tricuspid annulus in 43 patients (78.2%), mitral annulus in four patients (7.3%), paraseptal region in three patients (5.5%), and right ventricle mid-apical region in five patients (9.1%). Among 49 patients who planned for ablation therapy, the success rate was 91.8% (45 patients). Conclusion MAPs were most often ablated at the lateral aspect of the tricuspid annuli, sometimes at other sides of the tricuspid and mitral annuli, and infrequently in the right ventricle. The M potential mapping technique is likely to be a useful target for ablation of MAPs.
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Affiliation(s)
- Suat Gormel
- Department of Cardiology, Gulhane Research and Training Hospital, Ankara, Turkey
| | - Salim Yasar
- Department of Cardiology, Gulhane Research and Training Hospital, Ankara, Turkey
| | - Erkan Yildirim
- Department of Cardiology, Gulhane Research and Training Hospital, Ankara, Turkey
| | - Serkan Asil
- Department of Cardiology, Gulhane Research and Training Hospital, Ankara, Turkey
| | - Veysel Ozgur Baris
- Department of Cardiology, Gulhane Research and Training Hospital, Ankara, Turkey
| | - Yalcın Gokoglan
- Department of Cardiology, Gulhane Research and Training Hospital, Ankara, Turkey
| | - Murat Celik
- Department of Cardiology, Gulhane Research and Training Hospital, Ankara, Turkey
| | - Uygar Cagdas Yuksel
- Department of Cardiology, Gulhane Research and Training Hospital, Ankara, Turkey
| | | | - Hasan Kutsi Kabul
- Department of Cardiology, Gulhane Research and Training Hospital, Ankara, Turkey
| | - Sedat Kose
- Department of Cardiology, Liv Hospital, Ankara, Turkey
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Abstract
In some cases, atrioventricular reentrant arrhythmias are sustained by accessory pathways with peculiar electrophysiologic properties related to their specific anatomy. Most of these fibers, which may be responsible for variants of ventricular preexcitation, show decremental conduction properties due to a nodelike aspect or a peculiar tortuous anatomic route across the atrioventricular groove. Moreover, some fibers do not actively sustain any reentrant circuit and can be only involved as bystander in other arrhythmias. Although rare, these accessory pathway variants should be properly diagnosed using noninvasive and invasive methods to guide catheter ablation procedures when needed.
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3
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Egami Y, Yano M, Nishino M, Tanouchi J. A short RP tachycardia with alternating ventriculoatrial interval, but identical atrial activation sequence: What is the mechanism? HeartRhythm Case Rep 2020; 6:535-538. [PMID: 32817836 PMCID: PMC7424295 DOI: 10.1016/j.hrcr.2020.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Cardona-Guarache R, Han FT, Nguyen DT, Chicos AB, Badhwar N, Knight BP, Johnson CJ, Heaven D, Scheinman MM. Ablation of Supraventricular Tachycardias From Concealed Left-Sided Nodoventricular and Nodofascicular Accessory Pathways. Circ Arrhythm Electrophysiol 2020; 13:e007853. [DOI: 10.1161/circep.119.007853] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Nodoventricular and nodofascicular accessory pathways (AP) are uncommon connections between the atrioventricular node and the fascicles or ventricles.
Methods:
Five patients with nodofascicular or nodoventricular tachycardia were studied.
Results:
We identified 5 patients with concealed, left-sided nodoventricular (n=4), and nodofascicular (n=1) AP. We proved the participation of AP in tachycardia by delivering His-synchronous premature ventricular contractions that either delayed the subsequent atrial electrogram or terminated the tachycardia (n=3), and by observing an increase in VA interval coincident with left bundle branch block (n=2). The APs were not atrioventricular pathways because the septal VA interval during tachycardia was <70 ms in 3, 1 had spontaneous atrioventricular dissociation, and in 1 the atria were dissociated from the circuit with atrial overdrive pacing. Entrainment from the right ventricle showed ventricular fusion in 4 out of 5 cases. A left-sided origin of the AP was suspected after failed ablation of the right inferior extension of atrioventricular node in 3 cases and by observing a VA increase with left bundle branch block in 2 cases. The nodofascicular and 3 of the nodoventricular AP were successfully ablated from within the proximal coronary sinus (CS) guided by recorded potentials at the roof of the CS, and 1 nodoventricular AP was ablated via a transseptal approach near the CS os.
Conclusions:
Left-sided nodofascicular and nodoventricular AP appear to connect the ventricles with the CS musculature in the region of the CS os. Mapping and successful ablation sites can be guided by recording potentials within or near the CS os.
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Affiliation(s)
- Ricardo Cardona-Guarache
- Division of Cardiology, University of California San Francisco, San Francisco, CA (R.C.-G., M.M.S.)
| | - Frederick T. Han
- Division of Cardiology, University of California San Diego, La Jolla (F.T.H.)
| | - Duy T. Nguyen
- Division of Cardiology, Stanford University, Palo Alto, CA (D.T.N., N.B.)
| | - Alexandru B. Chicos
- Division of Cardiology, Northwestern University, Chicago, IL (A.B.C., B.P.K.)
| | - Nitish Badhwar
- Division of Cardiology, Stanford University, Palo Alto, CA (D.T.N., N.B.)
| | - Bradley P. Knight
- Division of Cardiology, Northwestern University, Chicago, IL (A.B.C., B.P.K.)
| | | | - David Heaven
- Division of Cardiology, Middlemore Hospital, Auckland, NZ (D.H.)
| | - Melvin M. Scheinman
- Division of Cardiology, University of California San Francisco, San Francisco, CA (R.C.-G., M.M.S.)
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Hoffmayer KS, Han FT, Singh D, Scheinman MM. Variants of accessory pathways. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2020; 43:21-29. [DOI: 10.1111/pace.13830] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 09/25/2019] [Accepted: 10/19/2019] [Indexed: 12/19/2022]
Affiliation(s)
- Kurt S. Hoffmayer
- Division of CardiologySection of ElectrophysiologyUniversity of California San Diego California
| | - Frederick T. Han
- Division of CardiologySection of ElectrophysiologyUniversity of California San Diego California
| | - David Singh
- Department of Cardiovascular DiseasesQueens Medical Center Honolulu Hawaii
| | - Melvin M. Scheinman
- Division of CardiologySection of ElectrophysiologyUniversity of California San Francisco California
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Soares Correa F, Lokhandwala Y, Sánchez-Quintana D, Mori S, Anderson RH, Wellens HJJ, Back Sternick E. Unusual variants of pre-excitation: From anatomy to ablation: Part III-Clinical presentation, electrophysiologic characteristics, when and how to ablate nodoventricular, nodofascicular, fasciculoventricular pathways, along with considerations of permanent junctional reciprocating tachycardia. J Cardiovasc Electrophysiol 2019; 30:3097-3115. [PMID: 31646696 DOI: 10.1111/jce.14247] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 09/24/2019] [Accepted: 10/12/2019] [Indexed: 11/30/2022]
Abstract
The recognition of the presence, location, and properties of unusual accessory pathways for atrioventricular conduction is an exciting, but frequently a difficult, challenge for the clinical cardiac arrhythmologist. In this third part of our series of reviews, we discuss the different steps required to come to the correct diagnosis and management decision in patients with nodofascicular, nodoventricular, and fasciculo-ventricular pathways. We also discuss the concealed accessory atrioventricular pathways with the properties of decremental retrograde conduction that are associated with the so-called permanent form of junctional reciprocating tachycardia. Careful analysis of the 12-lead electrocardiogram during sinus rhythm and tachycardias should always precede the investigation in the catheterization room. When using programmed electrical stimulation of the heart from different intracardiac locations, combined with activation mapping, it should be possible to localize both the proximal and distal ends of the accessory connections. This, in turn, should then permit the determination of their electrophysiologic properties, providing the answer to the question "are they incorporated in a tachycardia circuit?". It is this information that is essential for decision-making with regard to the need for catheter ablation, and if necessary, its appropriate site.
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Affiliation(s)
- Frederico Soares Correa
- Post Graduation Department, Faculdade de Ciências Médicas, Belo Horizonte, Brazil.,Arrhythmia and Electrophysiology Department, Biocor Institute, Nova Lima, Brazil
| | | | | | - Shumpei Mori
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Robert H Anderson
- Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Hein J J Wellens
- CARIM-Cardiovascular Research Centre Maastricht, Maastricht, The Netherlands
| | - Eduardo Back Sternick
- Post Graduation Department, Faculdade de Ciências Médicas, Belo Horizonte, Brazil.,Arrhythmia and Electrophysiology Department, Biocor Institute, Nova Lima, Brazil
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7
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Nazer B, Walters TE, Dewland TA, Naniwadekar A, Koruth JS, Najeeb Osman M, Intini A, Chen M, Biermann J, Steinfurt J, Kalman JM, Tanel RE, Lee BK, Badhwar N, Gerstenfeld EP, Scheinman MM. Variable Presentations and Ablation Sites for Manifest Nodoventricular/Nodofascicular Fibers. Circ Arrhythm Electrophysiol 2019; 12:e007337. [PMID: 31505948 DOI: 10.1161/circep.119.007337] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Nodofascicular and nodoventricular (NFV) accessory pathways connect the atrioventricular node and the Purkinje system or ventricular myocardium, respectively. Concealed NFV pathways participate as the retrograde limb of supraventricular tachycardia (SVT). Manifest NFV pathways can comprise the anterograde limb of wide-complex SVT but are quite rare. The purpose of this report is to highlight the electrophysiological properties and sites of ablation for manifest NFV pathways. METHODS Eight patients underwent electrophysiology studies for wide-complex tachycardia (3), for narrow-complex tachycardia (1), and preexcitation (4). RESULTS NFV was an integral part of the SVT circuit in 3 patients. Cases 1 to 2 were wide-complex tachycardia because of manifest NFV SVT. Case 3 was a bidirectional NFV that conducted retrograde during concealed NFV SVT and anterograde causing preexcitation during atrial pacing. NFV was a bystander during atrioventricular node re-entrant tachycardia, atrial fibrillation, atrial flutter, and orthodromic atrioventricular re-entrant tachycardia in 4 cases and caused only preexcitation in 1. Successful NFV ablation was achieved empirically in the slow pathway region in 1 case. In 5 cases, the ventricular insertion was mapped to the slow pathway region (2 cases) or septal right ventricle (3 cases). The NFV was not mapped in cases 5 and 7 because of its bystander role. QRS morphology of preexcitation predicted the right ventricle insertion sites in 4 of the 5 cases in which it was mapped. During follow-up, 1 patient noted recurrent palpitations but no documented SVT. CONCLUSIONS Manifest NFV may be critical for wide-complex tachycardia/manifest NFV SVT, act as the retrograde limb for narrow-complex tachycardia/concealed NFV SVT, or cause bystander preexcitation. Ablation should initially target the slow pathway region, with mapping of the right ventricle insertion site if slow pathway ablation is not successful. The QRS morphology of maximal preexcitation may be helpful in predicting successful right ventricle ablation site.
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Affiliation(s)
- Babak Nazer
- Knight Cardiovascular Institute, Oregon Health & Sciences University, Portland (B.N., T.A.D.)
| | - Tomos E Walters
- Cardiology Division (T.E.W., B.K.L., E.P.G., M.M.S.), University of California San Francisco
| | - Thomas A Dewland
- Knight Cardiovascular Institute, Oregon Health & Sciences University, Portland (B.N., T.A.D.)
| | - Aditi Naniwadekar
- Division of Cardiology, East Carolina University; Greenville, NC (A.N.)
| | - Jacob S Koruth
- Cardiology Division, Mount Sinai Medical Center; New York (J.S.K.)
| | - Mohammed Najeeb Osman
- Division of Cardiology, Louis Stokes Cleveland Veterans Affairs Medical Center & Case Western Reserve University, OH (M.N.O., A.I.)
| | - Anselma Intini
- Division of Cardiology, Louis Stokes Cleveland Veterans Affairs Medical Center & Case Western Reserve University, OH (M.N.O., A.I.)
| | - Minglong Chen
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, China (M.C.)
| | - Jurgen Biermann
- Department of Cardiology and Angiology, Heart Center Freiburg University, Germany (J.B., J.S.)
| | - Johannes Steinfurt
- Department of Cardiology and Angiology, Heart Center Freiburg University, Germany (J.B., J.S.)
| | - Jonathan M Kalman
- Department of Cardiology, Royal Melbourne Hospital, Parkville, Australia (J.M.K.)
| | - Ronn E Tanel
- Pediatric Cardiology Division (R.E.T.), University of California San Francisco
| | - Byron K Lee
- Cardiology Division (T.E.W., B.K.L., E.P.G., M.M.S.), University of California San Francisco
| | | | - Edward P Gerstenfeld
- Cardiology Division (T.E.W., B.K.L., E.P.G., M.M.S.), University of California San Francisco
| | - Melvin M Scheinman
- Cardiology Division (T.E.W., B.K.L., E.P.G., M.M.S.), University of California San Francisco
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8
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de Alencar Neto JN, Ramalho de Moraes SR, Back Sternick E, Wellens HJJ. Atypical bypass tracts: can they be recognized during sinus rhythm? Europace 2018; 21:208-218. [DOI: 10.1093/europace/euy079] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 03/20/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- José Nunes de Alencar Neto
- Universidade Federal de São Paulo, Escola Paulista de Medicina, Rua Napoleao de Barros, 715-Vila Clementino Sao Paulo, SP-CEP, São Paulo, Brazil
| | - Saulo Rodrigo Ramalho de Moraes
- Universidade Federal de São Paulo, Escola Paulista de Medicina, Rua Napoleao de Barros, 715-Vila Clementino Sao Paulo, SP-CEP, São Paulo, Brazil
| | - Eduardo Back Sternick
- Faculdade Ciências Médicas, Belo Horizonte, Alameda Ezequiel Dias, 275 - Centro, Belo Horizonte - MG, Brazil
- Arrhythmia Unit, Biocor Hospital, Alameda Oscar Niemeyer, 217 - Vila da Serra, Nova Lima - MG, Brazil
| | - Hein J J Wellens
- Cardiovascular Research Institute, Cardiovascular Research Institute, 6229 HX Maastricht, The Netherlands
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9
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Clinical Features and Sites of Ablation for Patients With Incessant Supraventricular Tachycardia From Concealed Nodofascicular and Nodoventricular Tachycardias. JACC Clin Electrophysiol 2017; 3:1547-1556. [PMID: 29759837 DOI: 10.1016/j.jacep.2017.07.015] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 06/22/2017] [Accepted: 07/13/2017] [Indexed: 02/07/2023]
Abstract
OBJECTIVES This study sought to describe the clinical features and sites of successful ablation for incessant nodofascicular (NF) and nodoventricular (NV) tachycardias. BACKGROUND Incessant supraventricular tachycardias have been associated with tachycardia-induced cardiomyopathies and have been previously attributed to permanent junctional reciprocating tachycardias, atrial tachycardias, and atrioventricular nodal re-entrant tachycardias. Incessant concealed NF and NV tachycardias have not been described previously. METHODS Three cases of incessant concealed NF and NV re-entrant tachycardias were identified from 2 centers. RESULTS The authors describe 3 cases with incessant supraventricular tachycardia resulting from NV (2 cases) and NF (1 case) pathways. Atrioventricular nodal re-entrant tachycardia was excluded by His synchronous premature ventricular complexes that either delayed or terminated the tachycardia. Ventricular pacing showed constant and progressive fusion in cases 1 and 3. In 2 cases, there was spontaneous initiation with a 1:2 response (cases 1 and 3); the presence of retrograde longitudinal dissociation or marked decremental pathway conduction in cases 1 and 3 sustains these tachycardias. The NV pathway was successfully ablated in the slow pathway region in case 3 and at the right bundle branch in case 1. The NF pathway was successfully ablated within the proximal coronary sinus in case 2. CONCLUSIONS This is the first report of incessant supraventricular tachycardia using concealed NF or NV pathways. These tachycardias demonstrated spontaneous initiation from sinus rhythm with a 1:2 response and retrograde longitudinal dissociation or marked decremental pathway conduction. Successful ablation was achieved at either right-sided sites or within the coronary sinus.
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10
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Hoffmayer KS, Lee BK, Vedantham V, Bhimani AA, Cakulev IT, Mackall JA, Sahadevan J, Rho RW, Scheinman MM. Variable clinical features and ablation of manifest nodofascicular/ventricular pathways. Circ Arrhythm Electrophysiol 2014; 8:117-27. [PMID: 25472957 DOI: 10.1161/circep.114.001924] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Manifest nodofascicular/ventricular (NFV) pathways are rare. METHODS AND RESULTS From 2008 to 2013, 4 cases were identified with manifest NFV pathways from 3 centers. The clinical findings and ablation sites are reported. All 4 cases presented with a wide complex tachycardia but with different QRS morphologies. Case 1 showed a left bundle branch block/superior axis, case 2 showed a right bundle branch block/inferior axis, case 3 showed a left bundle branch block/inferior axis, and case 4 showed a narrow QRS tachycardia and a wide complex tachycardia with a left bundle branch block/inferior axis. Three of the 4 tachycardias had atrioventricular dissociation ruling out extranodal accessory pathways, including atriofascicular pathways. Programmed extrastimuli showed evidence of a decremental accessory pathway in 3 of the 4 cases. Coexisting tachycardia mechanisms were seen in 3 of the 4 cases (atrioventricular nodal reentry tachycardia [2] and atrioventricular reentrant tachycardia [1]). Ablation in the slow pathway region eliminated the NFV pathway in 3 (transient in 1) with the other responding to surgical closure of a large atrial septal defect. The NFV pathway was a critical part of the tachycardia circuit in 1 and proved to be a bystander in the other 3 cases. CONCLUSIONS Manifest NFV pathways presented with variable QRS expression dependent on the ventricular insertion site and often coexisted with other tachycardia mechanisms (atrioventricular nodal reentry tachycardia and atrioventricular reentrant tachycardia). In most cases, the atrial insertion of the pathway was in or near the slow pathway region. The NFV pathways were either critical to the tachycardia circuit or served as bystanders.
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Affiliation(s)
- Kurt S Hoffmayer
- From the Division of Cardiovascular Medicine, Section of Electrophysiology, University of Wisconsin, Madison (K.S.H.); Division of Cardiovascular Medicine, Section of Electrophysiology, University of California, San Francisco (B.K.L., V.V., M.M.S.); Division of Cardiovascular Medicine, Department of Medicine, Harrington Heart Vascular Institute, University Hospitals Case Medical Center, Cleveland, OH (I.T.C., J.A.M., J.S.); Division of Cardiovascular Medicine, University of Texas Medical Branch, Galveston (A.A.B.); and Virginia Mason Medical Center, Seattle, WA (R.W.R.)
| | - Byron K Lee
- From the Division of Cardiovascular Medicine, Section of Electrophysiology, University of Wisconsin, Madison (K.S.H.); Division of Cardiovascular Medicine, Section of Electrophysiology, University of California, San Francisco (B.K.L., V.V., M.M.S.); Division of Cardiovascular Medicine, Department of Medicine, Harrington Heart Vascular Institute, University Hospitals Case Medical Center, Cleveland, OH (I.T.C., J.A.M., J.S.); Division of Cardiovascular Medicine, University of Texas Medical Branch, Galveston (A.A.B.); and Virginia Mason Medical Center, Seattle, WA (R.W.R.)
| | - Vasanth Vedantham
- From the Division of Cardiovascular Medicine, Section of Electrophysiology, University of Wisconsin, Madison (K.S.H.); Division of Cardiovascular Medicine, Section of Electrophysiology, University of California, San Francisco (B.K.L., V.V., M.M.S.); Division of Cardiovascular Medicine, Department of Medicine, Harrington Heart Vascular Institute, University Hospitals Case Medical Center, Cleveland, OH (I.T.C., J.A.M., J.S.); Division of Cardiovascular Medicine, University of Texas Medical Branch, Galveston (A.A.B.); and Virginia Mason Medical Center, Seattle, WA (R.W.R.)
| | - Ashish A Bhimani
- From the Division of Cardiovascular Medicine, Section of Electrophysiology, University of Wisconsin, Madison (K.S.H.); Division of Cardiovascular Medicine, Section of Electrophysiology, University of California, San Francisco (B.K.L., V.V., M.M.S.); Division of Cardiovascular Medicine, Department of Medicine, Harrington Heart Vascular Institute, University Hospitals Case Medical Center, Cleveland, OH (I.T.C., J.A.M., J.S.); Division of Cardiovascular Medicine, University of Texas Medical Branch, Galveston (A.A.B.); and Virginia Mason Medical Center, Seattle, WA (R.W.R.)
| | - Ivan T Cakulev
- From the Division of Cardiovascular Medicine, Section of Electrophysiology, University of Wisconsin, Madison (K.S.H.); Division of Cardiovascular Medicine, Section of Electrophysiology, University of California, San Francisco (B.K.L., V.V., M.M.S.); Division of Cardiovascular Medicine, Department of Medicine, Harrington Heart Vascular Institute, University Hospitals Case Medical Center, Cleveland, OH (I.T.C., J.A.M., J.S.); Division of Cardiovascular Medicine, University of Texas Medical Branch, Galveston (A.A.B.); and Virginia Mason Medical Center, Seattle, WA (R.W.R.)
| | - Judith A Mackall
- From the Division of Cardiovascular Medicine, Section of Electrophysiology, University of Wisconsin, Madison (K.S.H.); Division of Cardiovascular Medicine, Section of Electrophysiology, University of California, San Francisco (B.K.L., V.V., M.M.S.); Division of Cardiovascular Medicine, Department of Medicine, Harrington Heart Vascular Institute, University Hospitals Case Medical Center, Cleveland, OH (I.T.C., J.A.M., J.S.); Division of Cardiovascular Medicine, University of Texas Medical Branch, Galveston (A.A.B.); and Virginia Mason Medical Center, Seattle, WA (R.W.R.)
| | - Jayakumar Sahadevan
- From the Division of Cardiovascular Medicine, Section of Electrophysiology, University of Wisconsin, Madison (K.S.H.); Division of Cardiovascular Medicine, Section of Electrophysiology, University of California, San Francisco (B.K.L., V.V., M.M.S.); Division of Cardiovascular Medicine, Department of Medicine, Harrington Heart Vascular Institute, University Hospitals Case Medical Center, Cleveland, OH (I.T.C., J.A.M., J.S.); Division of Cardiovascular Medicine, University of Texas Medical Branch, Galveston (A.A.B.); and Virginia Mason Medical Center, Seattle, WA (R.W.R.)
| | - Robert W Rho
- From the Division of Cardiovascular Medicine, Section of Electrophysiology, University of Wisconsin, Madison (K.S.H.); Division of Cardiovascular Medicine, Section of Electrophysiology, University of California, San Francisco (B.K.L., V.V., M.M.S.); Division of Cardiovascular Medicine, Department of Medicine, Harrington Heart Vascular Institute, University Hospitals Case Medical Center, Cleveland, OH (I.T.C., J.A.M., J.S.); Division of Cardiovascular Medicine, University of Texas Medical Branch, Galveston (A.A.B.); and Virginia Mason Medical Center, Seattle, WA (R.W.R.)
| | - Melvin M Scheinman
- From the Division of Cardiovascular Medicine, Section of Electrophysiology, University of Wisconsin, Madison (K.S.H.); Division of Cardiovascular Medicine, Section of Electrophysiology, University of California, San Francisco (B.K.L., V.V., M.M.S.); Division of Cardiovascular Medicine, Department of Medicine, Harrington Heart Vascular Institute, University Hospitals Case Medical Center, Cleveland, OH (I.T.C., J.A.M., J.S.); Division of Cardiovascular Medicine, University of Texas Medical Branch, Galveston (A.A.B.); and Virginia Mason Medical Center, Seattle, WA (R.W.R.).
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11
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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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12
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NAMBOODIRI NARAYANAN, SHARMA GAUTAM, SANDERS PRASHANTHAN. Duality of Conduction in an Atriofascicular Pathway During Antidromic Tachycardia. Pacing Clin Electrophysiol 2009; 32:e7-8. [DOI: 10.1111/j.1540-8159.2009.02484.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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13
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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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14
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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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15
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Spontaneous automaticity arising from a successfully ablated Mahaim fiber. J Interv Card Electrophysiol 2007; 20:25-8. [PMID: 17943429 DOI: 10.1007/s10840-007-9164-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2007] [Accepted: 09/11/2007] [Indexed: 10/22/2022]
Abstract
The authors describe a 22-year-old woman with regular and irregular arrhythmias exhibiting left bundle branch block (LBBB) morphology at various heart rates. An atriofascicular fiber was diagnosed as the underlying mechanism for the antidromic reciprocating tachycardia. In addition, spontaneous automaticity of the Mahaim fiber was present during electrophysiologic study. The accessory pathway was ablated successfully, targeting a Mahaim potential at the supero-anterior tricuspid valve annulus. Relatively slow automatic rhythms with identical LBBB morphology were recorded immediately after ablation, as well as during long-term follow-up in a more sporadic and subclinical form. Abnormal automaticity arising from the distal portions of the remnant pathway was considered to be the origin of the slow ventricular rhythms in this peculiar case.
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Morita N, Kobayashi Y, Katoh T, Takano T. Anatomic and electrophysiologic evaluation of a right lateral atrioventricular Mahaim fiber. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2006; 28:1138-41. [PMID: 16221277 DOI: 10.1111/j.1540-8159.2005.00224.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
We report a patient who underwent an electrophysiologic study and radiofrequency catheter ablation for a right lateral Mahaim fiber. During sinus rhythm with overt preexcitation, propagation mapping was performed in the right ventricle using a three-dimensional electro-anatomical mapping system (CARTO). Small discrete potentials, which reflected the excitation of the Mahaim fiber, could be recorded along the line from the vicinity of the parental tricuspid annulus to approximately one-third of distal site from the base to the apex. The relationship of the timing of its potential to the anatomical location could be disclosed on recordings of the local electrogram and anatomical map.
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Affiliation(s)
- Norishige Morita
- First Department of Internal Medicine, Nippon Medical School, Tokyo, Japan.
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17
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Abstract
The aim of this review article is to discuss the electrocardiographic presentation of the so called variants of pre-excitation ("Mahaim fibers") during sinus rhythm and tachycardia.
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18
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Cao K, Chen M, Zou J, Shan Q, Chen C, Yang B, Zhu L, Xu D, Jin Y, Gonska BD. Narrow QRS Tachycardia with Ventriculoatrial Dissociation Mediated by a Left Fasciculoventricular Fiber. J Interv Card Electrophysiol 2005; 13:151-7. [PMID: 16133843 DOI: 10.1007/s10840-005-0204-6] [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] [Received: 07/19/2004] [Accepted: 04/12/2005] [Indexed: 10/25/2022]
Abstract
A 30-year-old man presented with narrow QRS tachycardia. The intracardiac electrocardiogram showed an atrial-HIS (AH) interval of 75 msec and a HIS-ventricular (HV) interval of 44 msec during baseline. Atrial incremental pacing revealed HV shortening, with apparent incomplete right bundle branch block (RBBB) morphology without QRS complex axis deviation. The induced tachycardia exhibited several QRS morphologies: a narrow QRS, complete RBBB and complete left bundle branch block (LBBB) morphology. Spontaneous conversion of the QRS pattern from wide to narrow was observed. The cycle length of the tachycardia was significantly shortened (from 316 to 272 ms) from LBBB morphology to narrow QRS complex. The atrial activation was dissociated from the ventricular activation during all tachycardias. Each QRS complex during tachycardia was preceded by a HIS deflection and HV interval was 35 ms, which was shorter than that of sinus rhythm. HIS deflection was earlier than right bundle potential during all kinds of tachycardia. This tachycardia is most likely mediated by a left fasciculoventricular fiber which connects the HIS bundle below the atrioventricular node to the myocardial tissue of the left ventricle. The HIS-Purkinje system is used as an antegrade conduction limb and the fasciculoventricular fiber as a retrograde limb in the tachycardia circuit.
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Affiliation(s)
- Kejiang Cao
- Department of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, People's Republic of China
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19
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Abstract
The case of an 8-year-old girl with incessant nonsustained left bundle branch block-like tachycardia refractory to antiarrhythmic drug therapy is reported. Electrophysiologic study revealed the presence of a right-sided accessory atriofascicular pathway. Episodes of nonsustained tachycardia were found to be based upon a dual response in AV conduction over the Mahaim fiber to one P wave. No reentrant tachycardia could be induced. The arrhythmia was cured by catheter ablation targeting a Mahaim potential at the right lateral tricuspid annulus. The findings can be explained by longitudinal dissociation in a single Mahaim fiber, a fiber distally diverging into two fibers with different conduction times, or (less likely) two closely located Mahaim fibers with different conduction times.
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Affiliation(s)
- Eduardo Back Sternick
- Department of Arrhythmia and Electrophysiology of BIOCOR Instituto, Nova Lima, Brazil.
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20
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Localization and radiofrequency ablation of atriofascicular pathways using electroanatomic mapping. J Electrocardiol 2003. [DOI: 10.1054/jelc.2003.50016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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21
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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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22
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Uchida F, Kasai A, Omichi C, Fujii E, Teramura S, Nakano T. Shortening of conduction time over arborized atrioventricular accessory pathway with Mahaim fibers physiology just before interruption during radiofrequency ablation. JAPANESE CIRCULATION JOURNAL 2000; 64:151-5. [PMID: 10716532 DOI: 10.1253/jcj.64.151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
A 21-year-old woman had paroxysmal wide QRS tachycardia with a left bundle branch block configuration and a retrograde conducted P wave just behind the QRS complex. An electrophysiological study revealed antidromic atrioventricular tachycardia involving an atrioventricular connection with decremental conduction as the anterograde limb and normal atrioventricular node as the retrograde limb. During constant pacing from the high right atrium (HRA) at the cycle length (CL) of 600 ms, the QRS configurations were not identical to those during the wide QRS tachycardia or constant pacing at the CL of less than 500 ms. The process by which this arborized atrioventricular accessory pathway with the Mahaim fibers physiology was interrupted by radiofrequency catheter ablation is described. Radiofrequency energy was delivered to the site recording a Mahaim potential at the tricuspid annulus during constant pacing from the HRA at the CL of 429 ms. The stimulus-QRS interval gradually shortened as it reached the power plateau without changing the preexcited QRS configuration. Shortening of the conduction time over the Mahiam pathway might have resulted in changing of the propagation from a slow to fast conduction zone or acceleration in response to thermal effect in a node-like structure on the atrial insertion site.
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Affiliation(s)
- F Uchida
- Department of Clinical Laboratory Medicine, Matsusaka City Hospital, Japan.
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23
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Tada H, Nogami A, Naito S, Oshima S, Taniguchi K, Kutsumi Y. Left posteroseptal Mahaim fiber associated with marked longitudinal dissociation. Pacing Clin Electrophysiol 1999; 22:1696-9. [PMID: 10598977 DOI: 10.1111/j.1540-8159.1999.tb00393.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
We report a patient who underwent radiofrequency catheter ablation of a left posteroseptal atrioventricular (AV) Mahaim fiber with a marked longitudinal dissociation. During atrial pacing, Wenckebach-type atrioventricular block over the accessory pathway was observed with progressive preexcitation and no change in polarity of the delta waves. The AV conduction curve was discontinuous, with a distinct "jump-up" in local AV conduction time of 84 ms. The earliest ventricular activation was recorded from the posteroseptal portion of the mitral annulus, and the unipolar electrogram from a distal electrode had a high, steep deflection with uniphasic QS-like activity with 62 ms of local AV conduction time.
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Affiliation(s)
- H Tada
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
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24
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Hluchy J, Schlegelmilch P, Schickel S, Jörger U, Jurkovicova O, Sabin GV. Radiofrequency ablation of a concealed nodoventricular Mahaim fiber guided by a discrete potential. J Cardiovasc Electrophysiol 1999; 10:603-10. [PMID: 10355703 DOI: 10.1111/j.1540-8167.1999.tb00718.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION We present the case of a 17-year-old woman who underwent an electrophysiological study and radiofrequency (RF) ablation of supraventricular tachycardia refractory to medical treatment. Two right-sided, concealed, nondecremental atrioventricular accessory pathways (AV-APs) involved in orthodromic circus movement tachycardias were identified. After RF ablation of both AV-APs, evidence of bidirectional dual AV nodal conduction was demonstrated and regular narrow complex tachycardia was induced. METHODS AND RESULTS During the tachycardia, retrograde slow and fast AV nodal pathway conduction with second-degree ventriculoatrial (VA) block and VA dissociation were observed. During the tachycardia with second-degree VA block, ventricular extrastimuli elicited during His-bundle refractoriness advanced the next His potential or terminated the tachycardia. Mapping the right atrial mid-septal region, a distinct high-frequency activation P potential was recorded in a discrete area, two thirds of the way from the His bundle toward the os of the coronary sinus. Detailed electrophysiologic testing with the recordable P potential demonstrated that the tachycardia utilized a concealed nodoventricular AP arising from the proximal slow AV nodal pathway. CONCLUSION The tachycardia with slow 1:1 VA conduction could be reset by ventricular extrastimuli elicited during His-bundle refractoriness advancing the subsequent activation P potential and atrial activation. RF ablation guided by recording of the activation P potential resulted in elimination of both the slow AV nodal pathway and the nodoventricular connection with preservation of the normal AV conduction system.
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Affiliation(s)
- J Hluchy
- Department of Cardiology and Angiology, Elisabeth Hospital, Germany
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25
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Nogami A, Suguta M, Tomita T, Naito S, Taniguchi K, Aonuma K, Iesaka Y. Novel form of atrial tachycardia originating at the atrioventricular annulus. Pacing Clin Electrophysiol 1998; 21:2691-4. [PMID: 9894665 DOI: 10.1111/j.1540-8159.1998.tb00051.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
We report two patients with reentrant atrial tachycardia that originated at the AV annulus. Atrial tachycardia originated in the posterior portion of mitral annulus in one patient (case 1) and the posterolateral portion of tricuspid annulus in one patient (case 2). Tachycardia was successfully eliminated by RF catheter ablation in both patients, with the catheter placed underneath the mitral valve in case 1 and on the tricuspid annulus in case 2. Spiky potentials were recorded in the diastolic phase of the atrium during tachycardia at the sites of successful ablation. Spiky potentials were also recorded after atrial electrogram during sinus rhythm, and showed decremental properties during atrial pacing. An accelerated atrial rhythm was observed during RF application, and tachycardia could not be induced after ablation in either patient. Tachycardia in these patients seemed to be due to reentrant tachycardia originating in the accessory AV node (Mahaim fiber) without ventricular connection.
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Affiliation(s)
- A Nogami
- Cardiology Division, Gunma Prefectural Cardiovascular Center, Japan.
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26
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Hamdan MH, Kalman JM, Lesh MD, Lee RJ, Saxon LA, Dorostkar P, Scheinman MM. Narrow complex tachycardia with VA block: diagnostic and therapeutic implications. Pacing Clin Electrophysiol 1998; 21:1196-206. [PMID: 9633061 DOI: 10.1111/j.1540-8159.1998.tb00178.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
To review our experience with cases of narrow complex tachycardia with VA block, highlighting the difficulties in the differential diagnosis, and the therapeutic implications. Prior reports of patients with narrow complex tachycardia with VA block consist of isolated case reports. The differential diagnosis of this disorder includes: automatic junctional tachycardia, AV nodal reentry with final upper common pathway block, concealed nodofascicular (ventricular) pathway, and intra-Hissian reentry. Between June 1994 and January 1996, six patients with narrow complex tachycardia with episodes of ventriculoatrial block were referred for evaluation. All six patients underwent attempted radiofrequency ablation of the putative arrhythmic site. Three of six patients had evidence suggestive of a nodofascicular tract. Intermittent antegrade conduction over a left-sided nodofascicular tract was present in two patients and the diagnosis of a concealed nodofascicular was made in the third patient after ruling out other tachycardia mechanisms. Two patients had automatic junctional tachycardia, and one patient had atrioventricular nodal reentry with proximal common pathway block. Attempted ablation in the posterior and mid-septum was unsuccessful in patients with nodofascicular tachycardia. In contrast, those with atrioventricular nodal reentry and automatic junctional tachycardia readily responded to ablation. The presence of a nodofascicular tachycardia should be suspected if: (1) intermittent antegrade preexcitation is recorded, (2) the tachycardia can be initiated with a single atrial premature producing two ventricular complexes, and (3) a single ventricular extrastimulus initiates SVT without a retrograde His deflection. The presence of a nodofascicular pathway is common in patients with narrow complex tachycardia and VA block. Unlike AV nodal reentry and automatic junctional tachycardia, the response to ablation is poor.
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Affiliation(s)
- M H Hamdan
- University of Texas, Southwestern/Dallas Veteran's Affairs Medical Center, USA.
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27
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Okishige K. Reply to the Editor:. J Cardiovasc Electrophysiol 1998. [DOI: 10.1111/j.1540-8167.1998.tb00935.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: 11/29/2022]
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28
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Okishige K, Goseki Y, Itoh A, Tsuboi N, Sasano T, Azegami K, Ohira H, Yamashita K, Satake S, Hiejima K. New electrophysiologic features and catheter ablation of atrioventricular and atriofascicular accessory pathways: evidence of decremental conduction and the anatomic structure of the Mahaim pathway. J Cardiovasc Electrophysiol 1998; 9:22-33. [PMID: 9475574 DOI: 10.1111/j.1540-8167.1998.tb00863.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Several modalities of catheter ablation have been proposed to eliminate Mahaim pathway conduction. However, limited research has been reported on the electrophysiologic nature of this pathway in its entity. METHODS AND RESULTS In seven patients, electrophysiologic study was performed, and radiofrequency energy was applied to investigate the electrophysiologic clues for successful ablation. In all seven patients, the Mahaim pathway was diagnosed as a right-sided atriofascicular or atrioventricular pathway with decremental properties. In two patients, two different kinds of electrograms were recorded through the ablation catheter positioned at the Mahaim pathway location: one was suggestive of conduction over the decremental portion, demonstrating a dulled potential; and the other of nondecremental conduction, demonstrating a spiked potential. All but one of the Mahaim pathways were eliminated successfully at the atrial origin where the spiked Mahaim potential was recorded. Radiofrequency energy application was performed at the slow potential site resulting in failure to eliminate the conduction over the Mahaim pathway. Conduction block at the site between the slow and fast potential recording sites was provoked by intravenous administration of adenosine, concomitant with a decrease in the amplitude of the Mahaim potential. In one patient, the clinical arrhythmia was a sustained monomorphic ventricular tachycardia originating from the ventricular end of the Mahaim fiber. CONCLUSION The identification of Mahaim spiked potentials may be the optimal method to permit their successful ablation. Detailed electrophysiologic assessment is indispensable for successful ablation of tachycardias associated with Mahaim fibers because tachycardias unassociated with Mahaim fibers can occur despite complete elimination of the Mahaim fiber.
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Affiliation(s)
- K Okishige
- Cardiac Electrophysiology Laboratory, Yokohama Red Cross Hospital, Japan
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29
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Abstract
Narrow complex tachycardia with VA block is rare. The differential diagnosis usually consists of (1) junctional tachycardia (JT) with retrograde block; (2) AV nodal reentrant tachycardia (AVNRT) with proximal common pathway block; and finally (3) nodofascicular tachycardia using the His-Purkinje system for antegrade conduction and a nodofascicular pathway for retrograde conduction. Analysis of tachycardia onset and termination, the effect of bundle branch block on tachycardia cycle length, and the response to atrial and ventricular premature depolarization must be carefully done. Making the correct diagnosis is crucial as the success rate in eliminating the tachycardia will depend on tachycardia mechanism.
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Affiliation(s)
- M H Hamdan
- UT Southwestern and Dallas VAMC, Cardiology Department, Texas 75216, USA
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30
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Mecca A, Telfer A, Lanzarotti C, Olshansky B. Symptomatic atrioventricular block in an atriofascicular pathway inserting into the left bundle branch without apparent atrioventricular node function. J Cardiovasc Electrophysiol 1997; 8:922-6. [PMID: 9261719 DOI: 10.1111/j.1540-8167.1997.tb00854.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
We report a patient with symptomatic AV block associated with conduction solely through an atriofascicular pathway that inserted into the left bundle branch. There was no apparent conduction present through the AV node. There was, however, passive activation through the His-Purkinje system. His-bundle pacing demonstrated normal conduction through both right and left bundles. This is the first report of such a case.
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Affiliation(s)
- A Mecca
- Section of Electrophysiology, Loyola University Medical Center, Maywood, Illinois 60153, USA
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31
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Okishige K, Azegami K, Goseki Y, Ohira H, Sasano T, Yamashita K, Satake S. Radiofrequency ablation of tachyarrhythmias in patients with Ebstein's anomaly. Int J Cardiol 1997; 60:171-80. [PMID: 9226288 DOI: 10.1016/s0167-5273(97)00089-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
We performed radiofrequency catheter ablation in five patients associated with Ebstein's anomaly to cure their refractory tachyarrhythmias. The presenting arrhythmias were four cases of orthodromic circus movement tachycardia using accessory pathways as a requisite limb, including one case of a Mahaim fiber and one of atrial flutter of common variety. All accessory pathways, including the Mahaim fiber, were ablated by RF energy delivered through the catheter placed at the AV annulus rather than the displaced anatomical AV groove. Interestingly, the antegrade or retrograde conduction interval over these accessory pathways was relatively longer than that of usual accessory pathways, and the accessory pathway potential was fractionated in some cases. The location of the atrioventricular node was displaced from the usual position to the postero-inferior area of Koch's triangle in one case. The configuration of the flutter wave was larger than usual in height as well as in width. All tachyarrhythmias were cured by RF catheter ablation. In the case of RF catheter ablation for patients with Ebstein's anomaly, close attention is indispensable in order to accomplish it safely and successfully, because of the anatomical and functional differences peculiar to Ebstein's anomaly.
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Affiliation(s)
- K Okishige
- Cardiovascular Department, Yokohama Red Cross Hospital, Naka-Ku, Japan
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32
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Callans DJ, Schwartzman D, Gottlieb CD, Marchlinski FE. Insights into the electrophysiology of accessory pathway-mediated arrhythmias provided by the catheter ablation experience: "learning while burning, part III". J Cardiovasc Electrophysiol 1996; 7:877-904. [PMID: 8884516 DOI: 10.1111/j.1540-8167.1996.tb00600.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: 02/02/2023]
Abstract
The success of catheter ablation has greatly improved the care of patients with paroxysmal tachycardias and has caused a revolution in the practice of electrophysiology. Some investigators have expressed that concern over procedural success in an increasingly interventional specialty threatens to eclipse attempts to understand the physiology of arrhythmia syndromes. Alternatively, due to the precise and directed nature of the lesions created with radiofrequency energy, catheter ablation procedures have allowed investigation to continue at a more focused level. In this article, the insights provided by the catheter ablation experience into the physiology of arrhythmias mediated by accessory AV pathways will be reviewed. Although the learning process was sometimes delayed by the nearly immediate success of radiofrequency catheter ablation, difficult situations have continued to renew efforts for understanding at a deeper level. Conscious attempts at "learning while burning" will provide the opportunity to investigate aspects of bypass tract physiology that remain incompletely characterized, such as partial response to therapy and late recurrence.
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Affiliation(s)
- D J Callans
- Clinical Electrophysiology Laboratory, Philadelphia Heart Institute, Presbyterian Medical Center, Pennsylvania, USA
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