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Krawczyk-Ożóg A, Hołda MK, Batko J, Jaśkiewicz K, Dziewierz A, Zdzierak B, Zasada W, Gil K, Hołda J. Description and prevalence of ventricular mitral annular disjunction: variation of normality or pathological variant? REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024:S1885-5857(24)00129-4. [PMID: 38641167 DOI: 10.1016/j.rec.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 04/03/2024] [Indexed: 04/21/2024]
Abstract
INTRODUCTION AND OBJECTIVES The aim of this study was to investigate a new variation of the atrial wall-mitral annulus-ventricular wall junction along the mural mitral leaflet and commissures: the ventricular mitral annular disjunction (v-MAD). This new variant is characterized by spatial displacement of the mitral leaflet hinge line by more than 2mm toward the left ventricle. METHODS We examined a cohort of autopsied human hearts (n=224, 21.9% females, 47.9±17.6 years) from patients without known cardiovascular disease to identify the presence of v-MAD. RESULTS More than half (57.1%) of the hearts showed no signs of MAD in the mural mitral leaflet or mitral commissures. However, v-MAD was found in 23.6% of cases, located within 20.1% of mural leaflets, 2.2% in superolateral commissures, and 1.3% in inferoseptal commissures. V-MAD was not uniformly distributed along the mitral annulus circumference, with the most frequent site being the P2 scallop (19.6% of hearts). The v-MAD height was significantly greater in mural leaflets than in commissures (4.4 mm±1.2 mm vs 2.1 mm±0.1 mm; P<.001). No specific variations in mitral valve morphology or anthropometrical features of donors were associated with the presence or distribution of v-MADs. Microscopic examinations revealed the overlap of the thin layer of atrial myocardium over ventricular myocardium in areas of v-MAD. CONCLUSIONS Our study is the first to present a detailed definition and morphometric description of v-MAD. Further studies should focus on the clinical significance of v-MAD to elucidate whether it represents a benign anatomical variant or a significant clinical anomaly.
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Affiliation(s)
- Agata Krawczyk-Ożóg
- Department of Anatomy, Heart Embryology and Anatomy Research Team (HEART), Jagiellonian University Medical College, Krakow, Poland; Clinical Department of Cardiology and Cardiovascular Interventions, Krakow University Hospital, Krakow, Poland.
| | - Mateusz K Hołda
- Department of Anatomy, Heart Embryology and Anatomy Research Team (HEART), Jagiellonian University Medical College, Krakow, Poland; Division of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom
| | - Jakub Batko
- Department of Anatomy, Heart Embryology and Anatomy Research Team (HEART), Jagiellonian University Medical College, Krakow, Poland
| | - Kacper Jaśkiewicz
- Department of Anatomy, Heart Embryology and Anatomy Research Team (HEART), Jagiellonian University Medical College, Krakow, Poland
| | - Artur Dziewierz
- Clinical Department of Cardiology and Cardiovascular Interventions, Krakow University Hospital, Krakow, Poland; 2nd Department of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Barbara Zdzierak
- Clinical Department of Cardiology and Cardiovascular Interventions, Krakow University Hospital, Krakow, Poland
| | - Wojciech Zasada
- Clinical Department of Cardiology and Cardiovascular Interventions, Krakow University Hospital, Krakow, Poland
| | - Krzysztof Gil
- Department of Pathophysiology, Jagiellonian University Medical College, Krakow, Poland
| | - Jakub Hołda
- Department of Anatomy, Heart Embryology and Anatomy Research Team (HEART), Jagiellonian University Medical College, Krakow, Poland. https://twitter.com/@Jakub_Batko_
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Kawabata M, Maeda S, Kamata T, Kawashima T, Yonai R, Okishige K, Atarashi H, Hirao K. Orthodromic AVRT With 2 Different Wide QRS Complexes Caused by Bilateral Bystander Nodoventricular Pathways. JACC Case Rep 2023; 28:102130. [PMID: 38204546 PMCID: PMC10774909 DOI: 10.1016/j.jaccas.2023.102130] [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] [Received: 08/02/2023] [Revised: 10/24/2023] [Accepted: 10/30/2023] [Indexed: 01/12/2024]
Abstract
We present a case of orthodromic atrioventricular re-entrant tachycardia exhibiting both right and left bundle branch block pattern wide QRS morphologies caused by bilateral bystander nodoventricular (NV) accessory pathways. These wide QRS morphologies came from pre-excitation accompanied by delta waves. In the context of NV accessory pathways, left-sided manifest NV accessory pathways are rare.
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Affiliation(s)
- Mihoko Kawabata
- Department of Cardiovascular Disease, AOI Universal Hospital, Kanagawa, Japan
| | - Shingo Maeda
- Department of Cardiovascular Disease, AOI Universal Hospital, Kanagawa, Japan
| | - Tatsuaki Kamata
- Department of Cardiovascular Disease, AOI Universal Hospital, Kanagawa, Japan
| | - Tomoyuki Kawashima
- Department of Cardiovascular Disease, AOI Universal Hospital, Kanagawa, Japan
| | - Ryo Yonai
- Department of Cardiovascular Disease, AOI Universal Hospital, Kanagawa, Japan
| | | | - Hirotsugu Atarashi
- Department of Cardiovascular Disease, AOI Universal Hospital, Kanagawa, Japan
| | - Kenzo Hirao
- Department of Cardiovascular Disease, AOI Universal Hospital, Kanagawa, Japan
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Perego M, Pariaut R, Moïse NS, Lombardo SF, Cavallini D, Santilli R. Electrocardiographic patterns of ventricular pre-excitation in dogs with right-sided accessory pathways. Vet Res Commun 2023; 47:1393-1403. [PMID: 36864330 DOI: 10.1007/s11259-023-10088-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 02/24/2023] [Indexed: 03/04/2023]
Abstract
INTRODUCTION The aim of the study was to describe the electrocardiographic features of ventricular pre-excitation (VPE) patterns characterized by the presence of delta (δ) wave, short P-δQRS interval, wide δQRS complexes in dogs with right-sided accessory pathways. ANIMALS, MATERIALS AND METHODS Twenty-six dogs with a confirmed accessory pathways (AP) via electrophysiological mapping were included. All dogs underwent a complete physical examination, 12-lead ECG, thoracic radiography, echocardiographic examination and electrophysiologic mapping. The AP were located in the following regions: right anterior, right posteroseptal, right posterior. The following parameters were determined: P-δQRS interval, δQRS duration, δQRS axis, δQRS morphology, δ-wave polarity, Q-wave, R-wave, R'-wave, S-wave amplitude, and R/S ratio. RESULTS In lead II, the median δQRS complex duration was 82.4 (IQR 7.2) and the median P-δQRS interval duration was 54.6 (IQR 4.2) msec. The median δQRS complex axis in the frontal plane was: + 68° (IQR 52.5) for right anterior APs, - 24 ° (IQR 24) for right postero-septal APs, - 43.5 ° (IQR 27.25) for right posterior APs (P = 0.007). In lead II, the polarity of the δ wave was positive in 5/5 right anterior APs and negative in 7/11 postero-septal APs and 8/10 in right posterior APs. In precordial leads of all dogs, R/S was ≤ 1 in V1 and > 1 in all leads from V2 to V6. CONCLUSION Surface electrocardiogram can be used to distinguish right anterior APs from right posterior and right postero-septal ahead of an invasive electrophysiological study.
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Affiliation(s)
- Manuela Perego
- Cardiovascular Division, Clinica Veterinaria Malpensa, Via Marconi 27, Samarate, Varese, 21017, Italy.
| | - Romain Pariaut
- College of Veterinary Medicine, Cornell University, Ithaca, NY, USA
| | - N Sydney Moïse
- College of Veterinary Medicine, Cornell University, Ithaca, NY, USA
| | - Sergio Federico Lombardo
- Cardiovascular Division, Clinica Veterinaria Malpensa, Via Marconi 27, Samarate, Varese, 21017, Italy
| | - Damiano Cavallini
- Dipartimento di Scienze Mediche Veterinarie, Università di Bologna, Ozzano dell'Emilia, BO, 40064, Italy
| | - Roberto Santilli
- Cardiovascular Division, Clinica Veterinaria Malpensa, Via Marconi 27, Samarate, Varese, 21017, Italy
- College of Veterinary Medicine, Cornell University, Ithaca, NY, USA
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Müller MJ, Fischer O, Dieks J, Schneider HE, Paul T, Krause U. Catheter Ablation of Coronary Sinus Accessory Pathways in the Young. Heart Rhythm 2023; 20:891-899. [PMID: 36898470 DOI: 10.1016/j.hrthm.2023.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/01/2023] [Accepted: 03/04/2023] [Indexed: 03/12/2023]
Abstract
BACKGROUND Accessory atrioventricular pathways (AP) are the most common tachycardia substrate for supraventricular tachycardia (SVT) in the young. Endocardial catheter ablation of AP may be unsuccessful in up to 5% due to a coronary sinus location. OBJECTIVE Data on ablation of accessory pathways within the coronary venous system (CVS) in the young is sparse. METHODS Analysis of feasibility, outcome, and safety in patients ≤18 years with coronary sinus accessory pathways (CS-AP) and catheter ablation via CVS in a tertiary pediatric electrophysiological referral center (05/2003-12/2021). Control group adjusted for age, weight, and pathway location was established from patients of the prospective European Multicenter Pediatric Ablation Registry who all had endocardial AP ablation. RESULTS 24 individuals had mapping and intended AP ablation within the CVS (age: 2.7-17.3 years, body weight: 15.0-72.0 kg). Due to proximity to coronary artery, ablation was withheld in 2/24. Overall procedural success was achieved in 20/22 (90.9%) study patients and in 46/48 (95.8%) controls. Coronary artery injury after RF ablation was noted in 2/22 (9%) study patients and in 1/48 (2%) controls. In CVS patients repeat SVT occurred in 5/22 (23%) during a median follow-up of 8.5 years, 4/5 underwent reablation resulting in 94.4% overall success. Controls were free from SVT during follow-up of 12 months as defined by registry protocol. CONCLUSIONS Success of CS-AP ablation in the young was comparable to endocardial AP-ablation. Substantial risk of coronary artery injury should be considered when CS-AP ablation is performed in the young.
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Affiliation(s)
- Matthias J Müller
- Department of Pediatric Cardiology, Intensive Care Medicine and Neonatology, Georg August University Medical Center, Göttingen, Germany.
| | - Olivia Fischer
- Department of Pediatric Cardiology, Intensive Care Medicine and Neonatology, Georg August University Medical Center, Göttingen, Germany
| | - Jana Dieks
- Department of Pediatric Cardiology, Intensive Care Medicine and Neonatology, Georg August University Medical Center, Göttingen, Germany
| | - Heike E Schneider
- Department of Pediatric Cardiology, Intensive Care Medicine and Neonatology, Georg August University Medical Center, Göttingen, Germany
| | - Thomas Paul
- Department of Pediatric Cardiology, Intensive Care Medicine and Neonatology, Georg August University Medical Center, Göttingen, Germany
| | - Ulrich Krause
- Department of Pediatric Cardiology, Intensive Care Medicine and Neonatology, Georg August University Medical Center, Göttingen, Germany
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Miyagi C, Fukamachi K, Miyamoto T, Kuban BD, Starling RC, Karimov JH. Characterization of left atrial assist device implantation: Early results of ex vivo anatomical assessment. Artif Organs 2023; 47:129-137. [PMID: 36106370 PMCID: PMC10086780 DOI: 10.1111/aor.14402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 08/03/2022] [Accepted: 09/06/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND The left atrial assist device (LAAD) is a novel pump that was developed specifically for the treatment of heart failure with preserved ejection fraction. The device is surgically implanted in the mitral position. This study aimed to characterize the various device-fitting configurations in the mitral annular position. METHODS Rapidly prototyped LAAD models (n = 5) were fabricated with five different driveline configurations: (A) annulus level/intra-cuff running; (B) supra-cuff/below coronary sinus (CS); (C) infra-cuff; (D) supra-annulus/supra-CS; (E) left ventricular free wall level. The 3D-printed models were implanted in extracted fresh porcine hearts (80-100 kg, adult, healthy porcine) and the proximity of anatomical structures between the driveline and CS and coronary artery (CA) were measured. RESULTS All five device configurations were evaluated for fitting. For the purpose of preventing blood clot formation around the driveline, the mitral annulus (MA) as a driveline pass-way (configuration A) has been considered advantageous with the current device, in that the driveline exposure to blood has been avoided. The CS does not exist at exactly the same level as the MA, and there is less risk of injuring it than using the left atrial free wall. However, there is an inevitable risk of damaging the CA, so careful visual inspection before inserting the driveline is needed. CONCLUSIONS Several options of driveline exteriorization were demonstrated, and the safety of each configuration was evaluated. Using the MA as a pathway for the driveline exit is considered to be a reasonable and safe method.
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Affiliation(s)
- Chihiro Miyagi
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Kiyotaka Fukamachi
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Takuma Miyamoto
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Barry D Kuban
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Electronics Core, Medical Device Solutions, Lerner Research Institute, Cleveland, Ohio, USA
| | - Randall C Starling
- Department of Cardiovascular Medicine, Miller Family Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Kaufman Center for Heart Failure Treatment and Recovery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jamshid H Karimov
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Kamada H, Nagase S, Miyamoto K, Aiba T, Kusano K. A case of antidromic atrioventricular reciprocating tachycardia via the atriofascicular pathway with suspected minor manifest fusion during ventricular pacing. J Arrhythm 2022; 38:656-659. [PMID: 35936041 PMCID: PMC9347201 DOI: 10.1002/joa3.12747] [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] [Received: 11/29/2021] [Revised: 06/01/2022] [Accepted: 06/13/2022] [Indexed: 11/25/2022] Open
Abstract
In this case with antidromic atrioventricular reciprocating tachycardia via the atriofascicular pathway, entrainment from the right ventricular apex showed minor constant fusion. This may indicate that an atriofascicular pathway with distal arborization can connect to the branch of the right bundle and partly to the working myocardium.
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Affiliation(s)
- Hiroyuki Kamada
- Department of Cardiovascular Medicine and HypertensionKagoshima University Graduate School of Medical and Dental SciencesKagoshimaJapan
| | - Satoshi Nagase
- Department of Advanced Arrhythmia and Translational Medical ScienceNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Koji Miyamoto
- Department of Cardiovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Takeshi Aiba
- Department of Cardiovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Kengo Kusano
- Department of Cardiovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
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Jansen H, Nürnberg JH, Veltmann C, Hebe J. Anatomy for ablation of atrioventricular nodal reentry tachycardia and accessory pathways. Herzschrittmacherther Elektrophysiol 2022; 33:133-147. [PMID: 35608665 DOI: 10.1007/s00399-022-00860-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 04/17/2022] [Indexed: 11/26/2022]
Abstract
The atrioventricular (AV) valve plane and the central septum are of particular importance for electrophysiological diagnosis and interventional therapy of supraventricular tachycardias because accessory electrical connections of various types may be present in addition to the specific conduction system. Although modern 3D electroanatomic reconstruction systems including high-density mapping can be of great assistance, detailed knowledge of the anatomic structures involved, their complex three-dimensional arrangement, and their electrical properties in conjunction with electrophysiological features of supraventricular arrhythmias is essential for safe and efficient electrophysiological treatment. The aim of this article is to present current anatomical, topographical, and electrophysiological findings against the background of historical, seminal, and still indispensable literature.
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Kato Y, Matsuyama TA, Fujishiro M, Hashimoto M, Sone H, Onizuka-Yamochi T. Local Variation and Age-Related Change in Atrial and Ventricular Myocardial Contiguity at the Atrioventricular Junction in Human Hearts. Circ Rep 2022; 4:158-165. [PMID: 35434411 PMCID: PMC8979762 DOI: 10.1253/circrep.cr-22-0013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 02/22/2022] [Indexed: 11/09/2022] Open
Abstract
Background: We explored the histologic patterns of and age-related changes in atrial and ventricular myocardial contiguity at the left and right atrioventricular (AV) junction that could be a target site for catheter ablation. Methods and Results: Twenty-three structurally normal adult hearts obtained at autopsy were studied. The 2 AV annuli were divided into 13 clinically recognized portions in which we measured distance between the atrial and ventricular myocardium at the AV junction. Overall, measured distance was less on the right than left side (mean [±SD] 0.74±0.59 vs. 1.15±0.78 mm, respectively), and distance increased gradually with age. The gap was smallest at the anterolateral portion on the right side and posterolateral portion on the left side. Three specific features were noted, namely extension of the ventricular myocardium (coarse trabeculae) towards the atrium on the right side of the AV junction, extension of the atrial myocardium onto the AV valve leaflets, and a collection of small myocardial cells, perhaps including specialized cells, in the right anterolateral portion. No concealed AV muscular connections were found. Conclusions: Contiguity and separation of the myocardium at the AV junction have specific patterns, and myocardial proximity is influenced by age. These histologic features of the AV junction may prove to be informative for catheter ablation of tachyarrhythmias related to the AV junction.
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Affiliation(s)
- Yuki Kato
- Department of Legal Medicine, Showa University School of Medicine
| | | | - Masaya Fujishiro
- Department of Legal Medicine, Showa University School of Medicine
| | - Mari Hashimoto
- Department of Legal Medicine, Showa University School of Medicine
| | - Hiromoto Sone
- Department of Legal Medicine, Showa University School of Medicine
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