1
|
Chen M, Wang Z, Wang S, Liu Z, Li X, Yang H, Hu L, Wu Z, Li Q, Zhou S. Electrophysiological characteristics of right- and left-sided Mahaim accessory pathways: A single-center experience in China. Front Cardiovasc Med 2022; 9:1052465. [PMID: 36568537 PMCID: PMC9768021 DOI: 10.3389/fcvm.2022.1052465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 11/08/2022] [Indexed: 12/12/2022] Open
Abstract
Background Mahaim-type accessory pathways (MAPs) are rare accessory pathways (APs) with specific properties. They are mostly located in the right side of the heart but rarely exist on the left side. Objectives This study aims to analyze the clinical and electrophysiological (EP) characteristics of both-sided MAPs. Methods A total of 2,249 patients with AP from our center were enrolled between 1 January 2011 and 27 March 2022. During the EP study (EPS) 17 patients were diagnosed with MAPs (right-sided: n = 13, left-sided: n = 4) according to the properties of Mahaim fibers. Results MAPs constitute 0.75% of all APs. Out of 1,553 patients with left-sided APs, four patients (0.26%) were diagnosed with Mahaim fiber-mediated tachycardia. Out of 696 patients with right-sided APs, 13 patients (1.9%) were diagnosed with Mahaim fiber. Most Mahaim fibers were located at the free wall of the tricuspid and mitral annuli. Seven patients of right-sided MAPs were of atriofasicular type, six patients had right-sided MAPs, and all of the patients with left-sided MAPs were of atrioventricular (AV) type. The M potential only was detected in long-length MAPs. Coexistence with other supraventricular tachycardias (SVTs) was also observed both in patients with right-sided and left-sided MAPs. All the patients underwent radiofrequency ablation successfully. Only one patient had tachycardia recurrence during a follow-up. Conclusion Although MAPs are commonly located at right sides, left sites are not impossible. The M potential contributes to the improvement of the successful ablation.
Collapse
Affiliation(s)
- Mingxian Chen
- Department of Cardiology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Zhuo Wang
- Department of Cardiology, Wuhan Renmin Hospital of Wuhan University, Wuhan, China
| | - Songyun Wang
- Department of Cardiology, Wuhan Renmin Hospital of Wuhan University, Wuhan, China
| | - Zhenjiang Liu
- Department of Cardiology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Xuping Li
- Department of Cardiology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Hui Yang
- Department of Cardiology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Lin Hu
- Department of Cardiology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Zhihong Wu
- Department of Cardiology, The Second Xiangya Hospital of Central South University, Changsha, China,*Correspondence: Zhihong Wu
| | - Qiming Li
- Department of Cardiology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Shenghua Zhou
- Department of Cardiology, The Second Xiangya Hospital of Central South University, Changsha, China
| |
Collapse
|
2
|
Ozcan EE, Turan OE, Akdemir B, Inevi UD, Yilancioglu RY, Baskurt AA, Alak C, Bayrak F. Comparison of electrophysiological characteristics of right- and left-sided Mahaim-type accessory pathways. J Cardiovasc Electrophysiol 2021; 32:360-369. [PMID: 33355963 DOI: 10.1111/jce.14852] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 11/26/2020] [Accepted: 12/13/2020] [Indexed: 12/01/2022]
Abstract
AIMS Mahaim-type accessory pathways (MAPs) are generally right-sided due to the embryological differentiation, but left-sided localization is also possible. This study aims to compare the clinical and electrophysiological characteristics of right- and left-sided MAPs. METHODS Of 251 patients diagnosed with AP by electrophysiological study between November 2015 and February 2020, 12 patients with MAP were included (right sided n = 8, left sided n = 4). MAP was diagnosed if; (1) no retrograde conduction; (2) anterograde decremental conduction; (3) adenosine sensitivity; and (4) Mahaim potential at successful ablation site were present. RESULTS Ten of twelve MAPs were clustered on the lateral walls of the mitral (n = 3, 75%) and tricuspid annuli (n = 7, 87.5%). Right-sided MAPs were mostly long pathways extending toward the conduction system whereas left-sided MAPs were short extending toward the neighboring myocardium. For right- and left-sided APs, the median QRS times were 129 and 156 ms (p = .042), the median VAbl -RVApex intervals were -12 and 64 ms (p = .007), the median QRS-V(His) intervals were 16 and 86 ms (p = .120), and the median VAbl -QRS interval was -8 and 12 ms (p = .017), respectively. Coexistence of dual atrioventricular node physiology was observed only in right-sided APs (n = 3, 37.5%). CONCLUSION MAPs are more typically located on the right but may rarely be seen on the left. Catheter ablation was associated with high success without complications.
Collapse
Affiliation(s)
- Emin Evren Ozcan
- Department of Cardiology, Dokuz Eylul University School of Medicine, Izmir, Turkey
| | - Oguzhan Ekrem Turan
- Department of Cardiology, Dokuz Eylul University School of Medicine, Izmir, Turkey
| | - Baris Akdemir
- Department of Cardiology, Faculty of Medicine, Goztepe Medicalpark Hospital, Bahcesehir University, Istanbul, Turkey
| | | | | | - Ahmet Anil Baskurt
- Department of Cardiology, Dokuz Eylul University School of Medicine, Izmir, Turkey
| | - Cetin Alak
- Department of Cardiology, Dokuz Eylul University School of Medicine, Izmir, Turkey
| | - Fatih Bayrak
- Department of Cardiology, Acibadem Mehmet Ali Aydinlar University School of Medicine, Istanbul, Turkey
| |
Collapse
|
3
|
Matta M, Marazzato J, De Ponti R, Gaita F, Anselmino M. Ablation of Accessory Pathways with Uncommon Electrophysiologic Properties. Card Electrophysiol Clin 2020; 12:567-581. [PMID: 33162004 DOI: 10.1016/j.ccep.2020.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
In rare cases, atrioventricular reentrant arrhythmias are sustained by accessory pathways with peculiar electrophysiologic features that may be related to their specific anatomy. Most of these bundles show decremental nodelike conduction properties and sustain peculiar forms of arrhythmias that require careful differential diagnosis. On the other hand, some pathways do not actively sustain any reentrant circuit and should nevertheless be promptly recognized to avoid unnecessary ablation attempts. Although rare, these variants of accessory pathway should be known to warrant a safe and effective catheter ablation procedure.
Collapse
Affiliation(s)
- Mario Matta
- Cardiology Division, Sant'Andrea Hospital, corso Mario Abbiate, 21, Vercelli 13100, Italy
| | - Jacopo Marazzato
- Department of Heart and Vessels, Ospedale di Circolo, Viale Borri, 57, Varese 21100, Italy; Department of Medicine and Surgery, University of Insubria, Viale Guicciardini, 9, Varese 21100, Italy
| | - Roberto De Ponti
- Department of Heart and Vessels, Ospedale di Circolo, Viale Borri, 57, Varese 21100, Italy; Department of Medicine and Surgery, University of Insubria, Viale Guicciardini, 9, Varese 21100, Italy
| | - Fiorenzo Gaita
- Cardiology Unit, J Medical Via Druento, 153/56, Turin 10151, Italy
| | - Matteo Anselmino
- Cardiology Division, Department of Medical Sciences, "Città della Salute e della Scienza di Torino" Hospital, University of Turin, Corso Bramante, 88, Turin 10126, Italy.
| |
Collapse
|
4
|
Izumi G, Yokoshiki H, Sasaki R, Chiba Y, Yamazawa H, Takeda A. Fast pathway ablation unmasks nodoventricular fibers in a 15-year-old patient with supraventricular tachycardia. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2020; 44:395-398. [PMID: 33047312 DOI: 10.1111/pace.14088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 09/18/2020] [Accepted: 10/11/2020] [Indexed: 11/28/2022]
Abstract
We described a 15-year-old boy who underwent the catheter ablation for the nodoventricular (NV) tachycardia that had difficulty in differentiation from atrioventricular nodal reentrant tachycardia with upper common pathway. The modification of the fast pathway revealed an anterograde conduction of the NV fiber. We successfully performed the catheter ablation targeting for the right ventricular insertion site of the NV fiber.
Collapse
Affiliation(s)
- Gaku Izumi
- Department of Pediatrics, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Hisashi Yokoshiki
- Department of Cardiovascular Medicine, Sapporo City General Hospital, Sapporo, Japan
| | - Ryo Sasaki
- Division of Medical Engineering Center, Hokkaido University Hospital, Sapporo, Japan
| | - Yuki Chiba
- Division of Medical Engineering Center, Hokkaido University Hospital, Sapporo, Japan
| | - Hirokuni Yamazawa
- Department of Pediatrics, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Atsuhito Takeda
- Department of Pediatrics, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| |
Collapse
|
5
|
Kara M, Korkmaz A, Karimli E, Simsek E, Ozeke O, Cay S, Ozcan F, Aras D, Topaloglu S. A narrow QRS complex during a left bundle branch block morphology wide QRS tachycardia: A clue for manifest or bystander involvement of nodofascicular pathway? J Cardiovasc Electrophysiol 2020; 31:552-556. [PMID: 31916620 DOI: 10.1111/jce.14343] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 12/19/2019] [Accepted: 12/23/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Meryem Kara
- Department of Cardiology, Ankara City Hospital, Health Sciences University, Ankara, Turkey
| | - Ahmet Korkmaz
- Department of Cardiology, Ankara City Hospital, Health Sciences University, Ankara, Turkey
| | - Emin Karimli
- Department of Cardiology, Ankara City Hospital, Health Sciences University, Ankara, Turkey
| | - Evrim Simsek
- Department of Cardiology, Ankara City Hospital, Health Sciences University, Ankara, Turkey.,Department of Cardiology, Ege University, İzmir, Turkey
| | - Ozcan Ozeke
- Department of Cardiology, Ankara City Hospital, Health Sciences University, Ankara, Turkey
| | - Serkan Cay
- Department of Cardiology, Ankara City Hospital, Health Sciences University, Ankara, Turkey
| | - Firat Ozcan
- Department of Cardiology, Ankara City Hospital, Health Sciences University, Ankara, Turkey
| | - Dursun Aras
- Department of Cardiology, Ankara City Hospital, Health Sciences University, Ankara, Turkey
| | - Serkan Topaloglu
- Department of Cardiology, Ankara City Hospital, Health Sciences University, Ankara, Turkey
| |
Collapse
|
6
|
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
| |
Collapse
|
7
|
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.
Collapse
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
| |
Collapse
|
8
|
Mahaim pathway tachycardia versus bystander ventricular tachycardia: A distinction without a difference. HeartRhythm Case Rep 2018; 4:92-97. [PMID: 29707482 PMCID: PMC5918180 DOI: 10.1016/j.hrcr.2017.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
|
9
|
Asakai H, Fenwick L, Hamilton RM. Electroanatomical voltage mapping of atrial Mahaim potentials to guide catheter ablation. HeartRhythm Case Rep 2017; 2:499-501. [PMID: 28507904 PMCID: PMC5426423 DOI: 10.1016/j.hrcr.2016.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Hiroko Asakai
- Labatt Family Heart Centre and Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children and Research Institute and University of Toronto, Toronto, Canada
| | - Laura Fenwick
- Labatt Family Heart Centre and Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children and Research Institute and University of Toronto, Toronto, Canada
| | - Robert M Hamilton
- Labatt Family Heart Centre and Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children and Research Institute and University of Toronto, Toronto, Canada
| |
Collapse
|
10
|
Abstract
The term Mahaim conduction is conventionally used to describe decrementally conducting connections between the right atrium or the AV node and the right ventricle in or close to the right bundle branch. Although such pathways are rare, their unique properties make their diagnosis and treatment cumbersome. In this article we review the published evidence, and discuss the electrocardiographic and electrophysiological characteristics as well as the anatomy and origin of these fibres.
Collapse
Affiliation(s)
| | - Hein J Wellens
- Cardiovascular Research Institute, Maastricht, the Netherlands
| | - Mark E Josephson
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| |
Collapse
|
11
|
Lim PCY, Chong DTT, Tan BY, Ho KL, Teo WS, Ching CK. Paroxysmal Supraventricular Tachycardia With Ventriculoatrial Block and QRS Duration Shortening: What Is the Mechanism? J Cardiovasc Electrophysiol 2015; 27:616-7. [PMID: 26552613 DOI: 10.1111/jce.12878] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Revised: 10/28/2015] [Accepted: 11/02/2015] [Indexed: 11/27/2022]
|
12
|
Abstract
The classic electrocardiogram in Wolff-Parkinson-White (WPW) syndrome is characterized by a short PR interval and prolonged QRS duration in the presence of sinus rhythm with initial slurring. The clinical syndrome associated with above electrocardiogram finding and the history of paroxysmal supraventricular tachycardia is referred to as Wolff-Parkinson-White syndrome. Various eponyms describing accessory or anomalous conduction pathways in addition to the normal pathway are collectively referred to as preexcitation syndromes. The latter form and associated eponyms are frequently used in literature despite controversy and disagreements over their actual anatomical existence and electrophysiological significance. This communication highlights inherent deficiencies in the knowledge that has existed since the use of such eponyms began. With the advent of curative ablation, initially surgical, and then catheter based, the knowledge gaps have been mostly filled with better delineation of the anatomic and electrophysiological properties of anomalous atrioventricular pathways. It seems reasonable, therefore, to revisit the clinical and electrophysiologic role of preexcitation syndromes in current practice.
Collapse
|
13
|
Bohora S. Wide QRS tachycardia changing to a narrow QRS tachycardia. What is the mechanism? Heart Rhythm 2015; 12:1698-700. [PMID: 25678056 DOI: 10.1016/j.hrthm.2015.02.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Indexed: 10/24/2022]
Affiliation(s)
- Shomu Bohora
- Department of Cardiology, U.N. Mehta I.C.R.C., Civil hospital campus, Asarwa, Ahmedabad, Gujarat, India.
| |
Collapse
|
14
|
Fujita S, Fujii E, Sugiura S, Ito M. Atrioventricular accessory pathway with anterograde decremental conduction property. BMJ Case Rep 2013; 2013:bcr-2013-009814. [PMID: 23780770 DOI: 10.1136/bcr-2013-009814] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We report a case of atrioventricular (AV) accessory pathway with anterograde decremental conduction property. The δ wave polarity suggested the presence of a right posteroseptal accessory AV pathway. During atrial pacing, Wenckebach-type AV block over the accessory pathway was observed with prolongation of the local AV conduction time without the change in QRS morphology. No retrograde ventriculoatrial conduction was observed. During mapping of the right midseptal area, mechanical conduction block at the level of the proximal input to the accessory pathway was induced repeatedly by catheter manipulation. Radiofrequency energy delivery eliminated the accessory pathway. In this case only the bump phenomenon was the best marker of successful ablation.
Collapse
Affiliation(s)
- Satoshi Fujita
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | | | | | | |
Collapse
|
15
|
VEDANTHAM VASANTH, JACKMAN WARRENM, SCHEINMAN MELVINM. Unexpected Potential Following Ablation of a Right Atriofascicular Accessory Pathway. J Cardiovasc Electrophysiol 2013; 24:939-41. [DOI: 10.1111/jce.12152] [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] [Received: 02/07/2013] [Revised: 03/15/2013] [Accepted: 03/18/2013] [Indexed: 11/30/2022]
Affiliation(s)
- VASANTH VEDANTHAM
- Department of Medicine, Cardiac Electrophysiology Section; University of California; San Francisco California USA
| | - WARREN M. JACKMAN
- Heart Rhythm Institute; University of Oklahoma Health Sciences Center; Oklahoma City Oklahoma USA
| | - MELVIN M. SCHEINMAN
- Department of Medicine, Cardiac Electrophysiology Section; University of California; San Francisco California USA
| |
Collapse
|
16
|
Leitch J, Barlow M. Radiofrequency ablation for pre-excitation syndromes and AV nodal re-entrant tachycardia. Heart Lung Circ 2012; 21:376-85. [PMID: 22578587 DOI: 10.1016/j.hlc.2012.03.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2012] [Revised: 03/25/2012] [Accepted: 03/27/2012] [Indexed: 10/28/2022]
Abstract
Radiofrequency catheter ablation for supraventricular tachycardia was introduced in 1990. Since then it has become the standard for definitive treatment of pre-excitation syndromes and atrioventricular re-entrant tachycardia. In general, catheter ablation of supraventricular tachycardia results in improved outcomes compared to pharmacologic treatment. Over 95% of patients will be successfully treated with catheter ablation with less than a 5% chance of recurrence and <1% risk of major complications.
Collapse
Affiliation(s)
- James Leitch
- Cardiology Department, John Hunter Hospital, Newcastle 2300, Australia.
| | | |
Collapse
|
17
|
Mönnig G, Wasmer K, Milberg P, Schulz P, Köbe J, Zellerhoff S, Kochhäuser S, Pott C, Hindricks G, Borggrefe M, Breithardt G, Eckardt L. Predictors of long-term success after catheter ablation of atriofascicular accessory pathways. Heart Rhythm 2012; 9:704-8. [DOI: 10.1016/j.hrthm.2011.12.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2011] [Indexed: 11/27/2022]
|
18
|
Kwon DS, Badhwar N. Rare Diagnosis of a Common Supraventricular Tachycardia. Card Electrophysiol Clin 2010; 2:221-224. [PMID: 28770754 DOI: 10.1016/j.ccep.2010.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
This case describes diagnostic maneuvers that will lead to an accurate diagnosis of a given A on V supraventricular tachycardia. The list of maneuvers described is not exhaustive but includes techniques to help diagnose a concealed NV/NF pathway mediated tachycardia that is in the differential diagnosis of a failed atrioventricular nodal re-entrant tachycardia ablation. The practicing electrophysiologist must be prepared to perform these maneuvers in order to ensure the safest and most focused ablation procedures.
Collapse
Affiliation(s)
- David S Kwon
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California, 500 Parnassus Avenue, MU 434, San Francisco, CA 94143, USA
| | | |
Collapse
|
19
|
Bradfield J, Buch E, Tung R, Shivkumar K. Recurrent irregular tachycardia that consistently terminates on a P wave: what is the mechanism? J Cardiovasc Electrophysiol 2010; 21:1062-3. [PMID: 20455981 DOI: 10.1111/j.1540-8167.2010.01781.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Jason Bradfield
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California 90095-1679, USA.
| | | | | | | |
Collapse
|
20
|
Gupta A, Hsia HH, Lo R, Zei PC. Electroanatomic localization of a slowly conducting atrioventricular (Mahaim) accessory pathway. J Interv Card Electrophysiol 2009; 31:119-24. [PMID: 19943099 DOI: 10.1007/s10840-009-9440-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2009] [Accepted: 08/24/2009] [Indexed: 11/24/2022]
Abstract
We present a case of a 34-year-old female with Ebstein's anomaly and symptomatic wide complex tachyarrhythmia. Electrophysiologic evaluation demonstrated antidromic tachycardia utilizing a right-sided decremental, slowly conducting atrioventricular pathway. Distinct accessory pathway potentials along the length of the bypass tract were sequentially recorded to define the anatomic course of the pathway, as uniquely represented on a three-dimensional electroanatomic map, and to successfully guide catheter ablation.
Collapse
Affiliation(s)
- Anurag Gupta
- Division of Cardiology, Department of Internal Medicine, Stanford University School of Medicine, Stanford, CA, USA.
| | | | | | | |
Collapse
|
21
|
Roberts-Thomson KC, Seiler J, Raymond JM, Stevenson WG. Exercise induced tachycardia with atrioventricular dissociation: What is the mechanism? Heart Rhythm 2009; 6:426-8. [DOI: 10.1016/j.hrthm.2008.03.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2008] [Indexed: 11/27/2022]
|
22
|
Bohora S, Dora SK, Namboodiri N, Valaparambil A, Tharakan J. Electrophysiology study and radiofrequency catheter ablation of atriofascicular tracts with decremental properties (Mahaim fibre) at the tricuspid annulus. Europace 2008; 10:1428-33. [DOI: 10.1093/europace/eun283] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
|
23
|
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]
|
24
|
LAU ERNESTW. Infraatrial Supraventricular Tachycardias: Mechanisms, Diagnosis, and Management. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2008; 31:490-8. [DOI: 10.1111/j.1540-8159.2008.01020.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
25
|
Quinn FR, Mitchell LB, Mardell AP, Dal Disler RN, Veenhuyzen GD. Entrainment Mapping of a Concealed Nodoventricular Accessory Pathway in a Man with Complete Heart Block and Tachycardia-Induced Cardiomyopathy. J Cardiovasc Electrophysiol 2007; 19:90-4. [PMID: 17666058 DOI: 10.1111/j.1540-8167.2007.00916.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
True nodoventricular (NV) accessory connections, as originally described by Mahaim, are rare entities, with the majority of previously reported cases now recognized as being due to decremental atriofascicular pathways. Here, we present a patient with incessant narrow and wide QRS complex tachycardia occurring in the setting of prior complete heart block. Entrainment mapping proved useful in diagnosing orthodromic reentry utilizing a concealed right septal NV pathway. The patient was successfully treated with radiofrequency ablation, resulting in a marked improvement in left ventricular function.
Collapse
Affiliation(s)
- F Russell Quinn
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | | | | | | | | |
Collapse
|
26
|
|
27
|
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.
Collapse
|
28
|
Papagiannis J, Vachtsevanos L, Rammos S, Kanter R. Cryoablation of a Nodoventricular Mahaim Fiber. J Interv Card Electrophysiol 2005; 14:111-6. [PMID: 16374559 DOI: 10.1007/s10840-005-4346-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2005] [Accepted: 08/18/2005] [Indexed: 10/25/2022]
Abstract
An 11-year old female presented with paroxysmal tachycardia and was diagnosed with a Mahaim fiber during electrophysiologic study. A preexcited tachycardia and the typical variety of AV nodal reentry tachycardia were induced at different times. During preexcited tachycardia, the His bundle electrogram followed the ventricular electrogram, and, introduction of atrial premature beats at different coupling intervals, advanced the peri-AV nodal atrial tissue, with no change in the ventricular cycle length, leading to a diagnosis of an antidromic tachycardia due to a nodoventricular fiber. Cryoablation at a mid-septal location under three-dimensional guidance successfully eliminated both tachycardias without detrimental effects to the AV node.
Collapse
Affiliation(s)
- John Papagiannis
- Division of Pediatric Cardiology, Onassis Cardiac Surgery Center, Athens, Greece, and Division of Pediatric Cardiology, Department of Pediatrics, Duke University Medical Center, USA.
| | | | | | | |
Collapse
|
29
|
Affiliation(s)
- Michael C Giudici
- Division of Cardiology, Genesis Heart Institute, Davenport, Iowa 52803, USA.
| | | |
Collapse
|
30
|
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]
|
31
|
Blaufox AD, Saul JP. Radiofrequency ablation of right-sided accessory pathways in pediatric patients. PROGRESS IN PEDIATRIC CARDIOLOGY 2001; 13:25-40. [PMID: 11413056 DOI: 10.1016/s1058-9813(01)00081-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Right free-wall and septal accessory pathways encompass the full spectrum of accessory pathway electrophysiology and are situated in complex anatomical arrangements. Understanding this diversity of physiology is necessary for the successful and safe elimination of these connections with transcatheter radiofrequency ablation. When radiofrequency catheter ablation of these pathways is attempted in children, anatomical relationships often become more complex, and spatial constraints require more adaptive techniques than in adults. It is clear that considerable progress has been made with radiofrequency catheter ablation, such that it is now first-line therapy for most children who have been diagnosed with one of the broad spectrum of clinical manifestations that result from the presence of these accessory connections. This review will discuss how accessory pathway electrophysiology and anatomy impact the clinical syndromes observed in children, and how these factors, as well as others particular to children, determine the approach, results and potential long-term consequences of radiofrequency catheter ablation of right-sided accessory pathways in the pediatric population.
Collapse
Affiliation(s)
- A D. Blaufox
- Medical University of South Carolina, Charleston, SC, USA
| | | |
Collapse
|
32
|
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.
Collapse
Affiliation(s)
- J Hluchy
- Department of Cardiology and Angiology, Elisabeth Hospital, Essen, Germany
| | | | | | | | | |
Collapse
|
33
|
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.
Collapse
Affiliation(s)
- F Uchida
- Department of Clinical Laboratory Medicine, Matsusaka City Hospital, Japan.
| | | | | | | | | | | |
Collapse
|
34
|
Chen JY, Chang KC, Lin YC, Lee H, Hung JS, Chou HT. Radiofrequency ablation of a right atriofascicular Mahaim fiber and two contralateral left free-wall accessory pathways. JAPANESE HEART JOURNAL 1999; 40:481-7. [PMID: 10611914 DOI: 10.1536/jhj.40.481] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
We report a rare combination of a right atriofascicular Mahaim fiber and two left-sided atrioventricular accessory pathways in a 57-year-old female presenting with an antidromic atrioventricular reciprocating tachycardia. Radiofrequency ablation was first targeted at the left lateral accessory pathway that served as the retrograde limb of the tachycardia. After elimination of the left lateral pathway, a bystander left posterolateral pathway was detected, and it too was successfully ablated. Although no tachycardia was reinducible, the Mahaim pathway was ablated because of its short effective refractory period. A discrete Mahaim potential recorded at the right atrial free-wall successfully guided the ablation.
Collapse
Affiliation(s)
- J Y Chen
- Department of Cardiology, China Medical College Hospital, Taichung, Taiwan
| | | | | | | | | | | |
Collapse
|
35
|
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.
Collapse
Affiliation(s)
- J Hluchy
- Department of Cardiology and Angiology, Elisabeth Hospital, Germany
| | | | | | | | | | | |
Collapse
|
36
|
Porkolab FL, Alpert BL, Scheinman MM. Failure of right atrial premature beats to reset atriofascicular tachycardia. Pacing Clin Electrophysiol 1999; 22:528-30. [PMID: 10192864 DOI: 10.1111/j.1540-8159.1999.tb00483.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
A patient with a right atriofascicular (Mahaim) tachycardia was found to have inducible antidromic supraventricular tachycardia, but atrial premature beats from the right atrial free wall failed to reset the tachycardia. An interesting transition from AV nodal reentry tachycardia to Mahaim tachycardia is also presented.
Collapse
Affiliation(s)
- F L Porkolab
- Electrophysiology Division, Western Pennsylvania Hospital, Pittsburgh, Western Pennsylvania Cardiol Association, Pittsburgh 15224-2257, USA
| | | | | |
Collapse
|
37
|
Evans SJ, Blumberg SM, Scheinman MM. A nodoventricular fiber associated with dual AV nodal conduction, AV nodal reentrant tachycardia, and anterior location of the slow AV nodal pathway. Pacing Clin Electrophysiol 1999; 22:119-22. [PMID: 9990610 DOI: 10.1111/j.1540-8159.1999.tb00309.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
We present a case of a patient with a nodoventricular tract, associated with dual AV nodal conduction and AV nodal reentrant tachycardia, and an anteroseptal location of the slow AV nodal pathway. The remarkable feature of this case is the site of successful ablation, in the anteroseptum just anterior and superior to the His bundle, where both preexcitation and dual AV nodal physiology were abolished.
Collapse
Affiliation(s)
- S J Evans
- Harris Chasanoff Heart Institute, Department of Medicine, Long Island Jewish Medical Center, New Hyde Park, New York 11042, USA
| | | | | |
Collapse
|
38
|
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.
Collapse
Affiliation(s)
- M H Hamdan
- UT Southwestern and Dallas VAMC, Cardiology Department, Texas 75216, USA
| | | | | |
Collapse
|
39
|
Johnson CT, Brooks C, Jaramillo J, Mickelsen S, Kusumoto FM. A left free-wall, decrementally conducting, atrioventricular (Mahaim) fiber: diagnosis at electrophysiological study and radiofrequency catheter ablation guided by direct recording of a Mahaim potential. Pacing Clin Electrophysiol 1997; 20:2486-8. [PMID: 9358491 DOI: 10.1111/j.1540-8159.1997.tb06089.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
A 64-year-old female with Wolff-Parkinson-White syndrome and an ECG demonstrating a right posterolateral accessory pathway was referred for electrophysiological study. During electrophysiological testing two AV pathways were identified: a right posterolateral pathway that displayed conventional electrophysiological properties: and a left free-wall pathway that conducted only anterogradely and demonstrated decremental properties. Two separate wide complex tachycardias were induced that utilized the left free-wall pathway anterogradely and either the AV node or the right posterolateral accessory pathway retrogradely. A discrete electrical potential on the free wall of the mitral annulus was identified during tachycardia and was utilized to facilitate mapping and ablation.
Collapse
Affiliation(s)
- C T Johnson
- Division of Cardiology, Lovelace Medical Center, Albuquerque, New Mexico 87108, USA
| | | | | | | | | |
Collapse
|
40
|
Kottkamp H, Hindricks G, Shenasa H, Chen X, Wichter T, Borggrefe M, Breithardt G. Variants of preexcitation--specialized atriofascicular pathways, nodofascicular pathways, and fasciculoventricular pathways: electrophysiologic findings and target sites for radiofrequency catheter ablation. J Cardiovasc Electrophysiol 1996; 7:916-30. [PMID: 8894934 DOI: 10.1111/j.1540-8167.1996.tb00466.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION In the present report, the electrophysiologic findings in patients with different types of variants of preexcitation, i.e., atriofascicular, nodofascicular, and fasciculoventricular fibers, and the results of radiofrequency catheter ablation using different target sites are described. METHODS AND RESULTS Twelve patients (mean age 36 +/- 17 years) with variants of the preexcitation syndromes underwent electrophysiologic study and radiofrequency catheter ablation. The atrial origin of atriofascicular pathways remote from the normal AV node was assessed by application of late atrial extrastimuli that advanced ("reset") the timing of the next QRS complex without anterograde penetration into the AV node. In patients with atriofascicular pathways, ablation of the accessory pathway or the retrograde fast AV node pathway was attempted. Ablation of the atriofascicular pathways was guided by a stimulus-delta wave interval mapping in the first five patients and by recording of atriofascicular pathway activation potentials in the next five patients. A nodofascicular pathway was suggested if VA dissociation occurred during tachycardia and if atrial extrastimuli failed to reset the tachycardia without anterograde penetration into the AV node. A fasciculoventricular connection was suggested if the proximal insertion of the accessory pathway was found to arise from the His bundle or bundle branches. The PR interval was expected within normal limits during sinus rhythm and the QRS complex to be slightly prolonged with a discrete slurring of the R wave, suggesting a small delta wave. Ten of the 12 patients had evidence for atriofascicular pathways and one patient each for a nodofascicular and fasciculoventricular pathway. In six patients, the atriofascicular pathways were successfully ablated, and in two patients, the retrograde fast AV node pathway. In one patient, a concealed right posteroseptal accessory AV pathway served as the retrograde limb and was successfully ablated. The nodofascicular pathway was shown to be a bystander during AV node reentrant tachycardia. After successful fast AV node pathway ablation resulting in marked PR prolongation, no preexcitation was present during sinus rhythm because of the proximal insertion of the nodofascicular pathway distal to the delay producing parts of the AV node. The proximal insertion of the fasciculoventricular pathway was suggested to arise distal to the AV node at the site of the penetrating AV bundle. The earliest ventricular activation at the His-bundle recording site indicated the ventricular insertion of this accessory connection into the ventricular summit. The fasciculoventricular connection gave rise to a fixed ventricular preexcitation and served as a bystander during orthodromic AV reentrant tachycardia incorporating a left-sided accessory AV pathway. CONCLUSION The majority of patients with variants of the preexcitation syndrome present with specialized atriofascicular pathways that seem to originate from remnants of the specialized AV ring tissue. Nodofascicular and fasciculoventricular pathways exist and may give rise to preexcitation, although their functional role in participation of clinical arrhythmias still needs to be elucidated. In the present study, both a fasciculoventricular pathway and a nodofascicular pathway acted as a bystander.
Collapse
Affiliation(s)
- H Kottkamp
- Hospital of the Westfälische Wilhelms-University, Department of Cardiology and Angiology, Münster, Germany
| | | | | | | | | | | | | |
Collapse
|
41
|
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.
Collapse
Affiliation(s)
- D J Callans
- Clinical Electrophysiology Laboratory, Philadelphia Heart Institute, Presbyterian Medical Center, Pennsylvania, USA
| | | | | | | |
Collapse
|
42
|
Morady F, Strickberger A, Man KC, Daoud E, Niebauer M, Goyal R, Harvey M, Bogun F. Reasons for prolonged or failed attempts at radiofrequency catheter ablation of accessory pathways. J Am Coll Cardiol 1996; 27:683-9. [PMID: 8606282 DOI: 10.1016/0735-1097(95)00493-9] [Citation(s) in RCA: 71] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVES The purpose of this study was to categorize the reasons for a prolonged or failed procedure in a series of patients undergoing catheter ablation of an accessory pathway. BACKGROUND Radiofrequency ablation of accessory pathways at times requires a lengthy procedure or a second ablation session, or both, and not prior studies have systematically investigated the reasons for this. METHODS In a consecutive series of 619 patients undergoing catheter ablation of an accessory pathway, the mean ablation time +/- SD was 68 +/- 64 min. The subjects of this study were 14 patients who had an ablation time >2 SD greater than the mean (>196 min) and 51 patients who required a second ablation session for a successful outcome. The accessory pathway in the 65 patients in this study was located in the right free wall in 19 patients (29%), septum in 14 (22%) and left free wall in 32 (49%). RESULTS The primary reasons for a lengthy or failed ablation attempt were 1) inability to position the ablation catheter at the effective target site (16 patients, 25%); 2) instability of the ablation catheter or inadequate tissue contact at the target site, or both (15 patients, 23%); 3) mapping error due to an oblique course of the accessory pathway (7 patients, 11%); 4) failure to recognize a posteroseptal accessory pathway as being left-sided instead of right-sided (4 patients, 6%); 5) other errors in accessory pathway localization (6 patients, 9%); 6) epicardial location of the accessory pathway (5 patients, 8%); 7) recurrent atrial fibrillation (2 patients, 3%); 8) occurrence of a complication (2 patients, 3%); 9) unusual right-sided accessory pathway that inserted in the anterior right ventricle, 2 cm away from the lateral tricuspid annulus (1 patient, 1.5%); and 10) unexplained factors (7 patients, 11%). The most common effective strategies employed to achieve a successful outcome in these patients were 1) substitution of a more experienced operator; 2) use of ablation catheters of varying configurations; 3) switching from a retrograde aortic to a trans-septal approach; 4) switching from an inferior to a superior vena caval approach; 5) use of a 60-cm guiding sheath; 6) detailed mapping of the atrial or ventricular insertion of the accessory pathway; and 7) searching within the coronary sinus for a presumed accessory pathway potential. CONCLUSIONS A lengthy or failed attempt at catheter ablation of an accessory pathway may be due to a variety of reasons, the most common of which are problems related to some aspect of catheter manipulation and errors in accessory pathway localization. Knowledge of the most common reasons for a lengthy or ineffective procedure may facilitate successful outcome of accessory pathway ablation.
Collapse
Affiliation(s)
- F Morady
- Division of Cardiology, Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor, Michigan 48109-0022, USA
| | | | | | | | | | | | | | | |
Collapse
|
43
|
Schoen WJ, Fujimura O. Variant preexcitation syndrome: a true nodoventricular mahaim fiber or an accessory atrioventricular pathway with decremental properties? J Cardiovasc Electrophysiol 1995; 6:1117-23. [PMID: 8720213 DOI: 10.1111/j.1540-8167.1995.tb00390.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
INTRODUCTION The differentiation between a nodoventricular fiber and an accessory atrioventricular (AV) pathway with long conduction times and decremental properties could be very difficult even at detained electrophysiologic study. METHODS AND RESULTS A 20-year-old male with a history of a wide QRS tachycardia underwent electrophysiologic study. Baseline intervals were normal. There was evidence of dual AV pathways, and a sudden increase in AH interval was associated with the emergence of a delta wave. The atrio-delta interval showed a progressive prolongation. The preexcited QRS complex was typical of a posteroseptal pathway, and the earliest ventricular activation site was recorded at the posteroseptal region. Retrograde conduction was exclusively over the normal conduction system. During ventricular extrastimulation, a sudden increase in HA interval was associated with anterograde conduction over the accessory pathway. The intervals between the stimulus artifact and the onset of the delta wave during atrial pacing from two atrial sites (S-Delta) were compared with those between the retrograde atrial electrogram on the His channel and the onset of the delta wave during ventricular pacing (A2HB-Delta). When pacing from the proximal coronary sinus, the shortest S-Delta interval did become shorter than the longest A2HB-Delta interval (155 vs 170 msec). CONCLUSION The finding that the S-Delta interval could become shorter than the A2HB-Delta interval provides strong evidence that this accessory pathway was not connected to the AV node but arose directly from the atrial tissue of the posteroseptal region.
Collapse
Affiliation(s)
- W J Schoen
- Arrhythmia Service, University of Kentucky Medical Center, Lexington, USA
| | | |
Collapse
|
44
|
Widman LE, Tong DA. An algorithm for complete enumeration of the mechanisms of supraventricular tachycardias that use multiple atrioventricular, AV nodal, and/or Mahaim pathways. Artif Intell Med 1995; 7:361-86. [PMID: 7581629 DOI: 10.1016/0933-3657(95)00010-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The EINTHOVEN system is a model-based expert system that interprets the cardiac rhythm from the electrocardiogram. It simulates the expected behavior of realistic semi-quantitative cardiac models constructed by heuristic rules to generate interpretations that include both text descriptions and event-by-event causal explanations in the form of ladder diagrams. The simulation has been limited by an inability to predict all possible behaviors of hearts with more than one reentrant circuit. We now describe an algorithm that overcomes this limitation. Its output has been validated by an independent possibility-tree analysis. Timing and storage measurements are presented for models with up to three slow atrioventricular nodal pathways, four atrioventricular pathways, and a single atriofascicular (Mahaim) pathway. This is the first report in the literature of an algorithm that enumerates all possible mechanisms for reentrant supraventricular tachycardias that use atrioventricular, atrioventricular nodal, and/or atriofascicular pathways in humans.
Collapse
Affiliation(s)
- L E Widman
- University of Oklahoma Health Sciences Center, Oklahoma City 73104, USA
| | | |
Collapse
|