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Przybylski R, Saravu Vijayashankar S, O'Leary ET, Hylind RJ, Noon J, Dionne A, DeWitt ES, Bezzerides VJ, Abrams DJ. Hypertrophic Cardiomyopathy and Ventricular Preexcitation in the Young: Cause and Accessory Pathway Characteristics. Circ Arrhythm Electrophysiol 2023; 16:e012191. [PMID: 37877314 PMCID: PMC10843507 DOI: 10.1161/circep.123.012191] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 10/10/2023] [Indexed: 10/26/2023]
Abstract
BACKGROUND The cause of hypertrophic cardiomyopathy (HCM) in the young is highly varied. Ventricular preexcitation (preexcitation) is well recognized, yet little is known about the specificity for any cause and the characteristics of the responsible accessory pathways (AP). METHODS Retrospective cohort study of patients <21 years of age with HCM/preexcitation from 2000 to 2022. The cause of HCM was defined as isolated HCM, storage disorder, metabolic disease, or genetic syndrome. Atrioventricular AP (true AP) were distinguished from fasciculoventricular fibers (FVF) using standard invasive electrophysiology study criteria. AP were defined as high risk if any of the following were <250 ms: shortest preexcited RR interval in atrial fibrillation, shortest paced preexcited cycle length, or anterograde AP effective refractory period. RESULTS We identified 345 patients with HCM and 28 (8%) had preexcitation (isolated HCM, 10/220; storage disorder, 8/17; metabolic disease, 5/19; and genetic syndrome, 5/89). Six (21%) patients had clinical atrial fibrillation (1 with shortest preexcited RR interval <250 ms). Twenty-two patients underwent electrophysiology study which identified 23 true AP and 16 FVF. Preexcitation was exclusively FVF mediated in 8 (36%) patients. Five (23%) patients had AP with high-risk conduction properties (including ≥1 patient in each etiologic group). Multiple AP were seen in 8 (36%) and AP plus FVF in 10 (45%) patients. Ablation was acutely successful in 13 of 14 patients with recurrence in 3. One procedure was complicated by complete heart block after ablation of a high-risk midseptal AP. There were significant differences in QRS amplitude and delta wave amplitude between groups. There were no surface ECG features that differentiated AP from FVF. CONCLUSIONS Young patients with HCM and preexcitation have a high likelihood of underlying storage disease or metabolic disease. Nonisolated HCM should be suspected in young patients with large QRS and delta wave amplitudes. Surface ECG is not adequate to discriminate preexcitation from a benign FVF from that secondary to potentially life-threatening AP.
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Affiliation(s)
- Robert Przybylski
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, MA
| | | | - Edward T O'Leary
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, MA
| | - Robyn J Hylind
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, MA
| | - Jennifer Noon
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, MA
| | - Audrey Dionne
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, MA
| | - Elizabeth S DeWitt
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, MA
| | | | - Dominic J Abrams
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, MA
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Unusual QRS complexes associated with the simultaneous presence of a right-sided accessory pathway, fasciculoventricular pathway, and incomplete right bundle branch block. J Cardiol Cases 2023; 27:101-104. [PMID: 36910041 PMCID: PMC9995657 DOI: 10.1016/j.jccase.2022.10.015] [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: 08/18/2022] [Revised: 10/01/2022] [Accepted: 10/26/2022] [Indexed: 11/17/2022] Open
Abstract
A 52-year-old man presented with delta waves on a body surface electrocardiogram, which suggested the presence of a right-sided accessory pathway (AP). Patients with right-sided APs generally have an rS pattern in leads V1-2, while he had an rS in lead V1 but an Rs in lead V2, which could not rule out the possibility of the presence of a septal AP or fasciculoventricular pathway (FVP). On the other hand, patients with septal APs or FVPs generally have a QS pattern in lead V1 instead of an rS pattern. An electrophysiological study demonstrated that the simultaneous presence of a right-sided posterolateral AP and FVP with incomplete right bundle branch block (ICRBBB) generated those unusual QRS complexes. The FVP arose distal to the site with ICRBBB, and the ICRBBB delayed the initiation of the FVP conduction. The delayed QS and Rs waves in leads V1-2 generated by the FVP conduction with ICRBBB appeared to produce rS and Rs patterns in leads V1-2, respectively. A radiofrequency application along the posterolateral tricuspid annulus eliminated the right-sided AP conduction. If the localization of APs based on the QRS morphology is difficult, multiple APs or an FVP with a conduction system disturbance should be noted. Learning objective Patients with right-sided posterolateral accessory pathways (APs) generally have an rS pattern in lead V2, while patients with fasciculoventricular pathways (FVPs) generally have a QS pattern in lead V1. The present case with a suspected right-sided posterolateral AP had unusual QRS complexes, an rS in lead V1, Rs in lead V2, and monophasic R in leads V3-6, which were associated with the simultaneous presence of a right-sided posterolateral AP, FVP, and incomplete right bundle branch block.
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Ali H, De Lucia C, Cristiano E, Lupo P, Foresti S, De Ambroggi G, Turturiello D, Paganini EM, Bessi R, Farghaly AAA, Francia P, Cappato R. A Single-lead ECG algorithm to differentiate right from left manifest accessory pathways: A reappraisal of the P-Delta interval. J Cardiovasc Electrophysiol 2023; 34:598-606. [PMID: 36640425 DOI: 10.1111/jce.15818] [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: 11/02/2022] [Revised: 12/29/2022] [Accepted: 01/09/2023] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Despite numerous ECG algorithms being developed to localize the site of manifest accessory pathways (AP), they often require stepwise multiple-lead analysis with variable accuracy, limitations, and reproducibility. The study aimed to develop a single-lead ECG algorithm incorporating the P-Delta interval (PDI) as an adjunct criterion to discriminate between right and left manifest AP. METHODS Consecutive WPW patients undergoing electrophysiological study (EPS) were retrospectively recruited and split into a derivation and validation group (1:1 ratio). Sinus rhythm ECG analysis in lead V1 was performed by three independent investigators blinded to the EPS results. Conventional ECG parameters and PDI were assessed through the global cohort. RESULTS A total of 140 WPW patients were included (70 for each group). A score-based, single-lead ECG algorithm was developed through derivation analysis incorporating the PDI, R/S ratio, and QRS onset polarity in lead V1. The validation group analysis confirmed the proposed algorithm's high accuracy (95%), which was superior to the previous ones in predicting the AP side (p < 0.05). A score of ≤+1 was 96.5% accurate in predicting right AP while a score of ≥+2 was 92.5% accurate in predicting left AP. The new algorithm maintained optimal performance in specific subgroups of the global cohort showing an accuracy rate of 90%, 92%, and 96% in minimal pre-excitation, posteroseptal AP, and pediatric patients, respectively. CONCLUSIONS A novel single-lead ECG algorithm incorporating the PDI interval with previous conventional criteria showed high accuracy in differentiating right from left manifest AP comprising pediatric and minimal pre-excitation subgroups in the current study.
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Affiliation(s)
- Hussam Ali
- Arrhythmia & Electrophysiology Center, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
| | - Carmine De Lucia
- Arrhythmia & Electrophysiology Center, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
| | - Ernesto Cristiano
- Arrhythmia & Electrophysiology Center, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy.,Department of Clinical and Molecular Medicine, Division of Cardiology, St. Andrea Hospital, Sapienza University, Rome, Italy
| | - Pierpaolo Lupo
- Arrhythmia & Electrophysiology Center, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
| | - Sara Foresti
- Arrhythmia & Electrophysiology Center, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
| | - Guido De Ambroggi
- Arrhythmia & Electrophysiology Center, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
| | - Dario Turturiello
- Arrhythmia & Electrophysiology Center, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
| | - Edoardo Maria Paganini
- Arrhythmia & Electrophysiology Center, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
| | - Riccardo Bessi
- Arrhythmia & Electrophysiology Center, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
| | - Ahmad Abdelrady Abdelsalam Farghaly
- Arrhythmia & Electrophysiology Center, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy.,Cardiovascular Department, Assiut University, Assiut, Egypt
| | - Pietro Francia
- Department of Clinical and Molecular Medicine, Division of Cardiology, St. Andrea Hospital, Sapienza University, Rome, Italy
| | - Riccardo Cappato
- Arrhythmia & Electrophysiology Center, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
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Sulu A, Kafali HC, Sahin GT, Ergul Y. Electrocardiographic and electrophysiological characteristics of fasciculoventricular fibers in children. Pacing Clin Electrophysiol 2022; 45:1165-1171. [PMID: 35866690 DOI: 10.1111/pace.14568] [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: 04/10/2022] [Revised: 06/26/2022] [Accepted: 07/08/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Fasciculoventricular fiber (FVF) that does not cause tachyarrhythmia is a rare form of ventricular preexcitation, which is important to distinguish from Kent fibers. Although adenosine and some electrocardiographic features are important in the differentiation of Wolff Parkinson White (WPW) than FVF, a clear distinction may not always be possible without an electrophysiological study (EPS). In this study, we aimed to present the clinical and electrophysiological features of our pediatric patients with fasciculoventricular fiber. PATIENTS AND METHOD Between October 2013 and September 2021, 565 patients who underwent electrophysiological studies due to ventricular preexcitation in our clinic were screened in the study, and 27 (4.7%) patients with fasciculoventricular fiber were included. The data of the patients were obtained from the file records using the electronic internet database system Filemaker®. Electrophysiological study age, weight, gender, symptom, and presence of congenital heart disease of the patients were obtained from the file records. Accessory pathway localization was evaluated according to the modified Arruda algorithm in pre-procedural electrocardiography. In addition, delta wave amplitudes were measured in the first 40 ms from the surface ECG. PR interval, QRS interval, and delta wave amplitude were recorded before and after ablation in patients with additional accessory pathways. Post-procedure values were included in the FVF group. RESULTS The mean age of the patients was 11.47±4.25 years. 70.4% of the reasons for admission were symptoms such as palpitations and syncope. Two patients had hypertrophic cardiomyopathy and one patient had ccTGA. In the electrophysiological study, additional manifest WPW was found in 9 (33%) patients (3 patients with high risk, 6 patients with orthodromic supraventricular tachycardia), focal atrial tachycardia in a patient, and atrioventricular nodal reentry tachycardia in a patient. While the delta wave amplitude was found to be 2.56±1.38(1-5.5) mm in the first 40 ms in surface electrocardiography in 9 patients with additional accessory pathway, it was found to be 1.64±0.67(0.5-3) mm in the FVF group. There was no statistically significant difference between the two groups (p = 0.398). Delta wave amplitude >3.5mm was not detected in any patient with isolated FVF. Interestingly, delta wave amplitude was <3.5mm in 7 (78%) of 9 patients who were identified and ablated with an additional accessory pathway. 19 of the patients (59.3%) were adenosine-responsive (18 isolated FVF, 1 manifest AP+FVF adenosine-responsive. 8 patients with other manifest AP + FVF had no pre-procedural adenosine-asystole response, and all of them QRS were expanded). CONCLUSION Although the fasciculoventricular fibers themselves are not the cause of tachyarrhythmia, the accessory pathway and other tachyarrhythmia substrate frequency accompanying these cases are quite high (approximately 40%) in EPS. The delta wave characteristics of ablated patients are very similar to FVF patients. While all patients with isolated FVF were adenosine responsive, most of those with additional manifest WPW were unresponsive. Therefore, performing EPS in patients with suspected FVF based on surface ECG features seems to be important for the detection of additional tachyarrhythmias and risky accessory pathways. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Ayse Sulu
- Department of Pediatric Cardiology, University of Health Sciences Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey.,Eskisehir Osmangazi University Faculty of Medicine, Eskisehir, Turkey
| | - Hasan Candas Kafali
- Department of Pediatric Cardiology, University of Health Sciences Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey
| | - Gulhan Tunca Sahin
- Department of Pediatric Cardiology, University of Health Sciences Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey
| | - Yakup Ergul
- Department of Pediatric Cardiology, University of Health Sciences Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey
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Barresi NV, Marcus BS, Beach CM, Vinocur JM. An unusual cause of repolarization abnormality after congenital heart surgery: A case report. J Electrocardiol 2022; 72:91-94. [DOI: 10.1016/j.jelectrocard.2022.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 03/18/2022] [Indexed: 11/24/2022]
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6
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Yang L, Chen Z, Zhang M. Case Report: An Unusual Case of Fasciculoventricular Pathway. Front Cardiovasc Med 2022; 9:818275. [PMID: 35252397 PMCID: PMC8896400 DOI: 10.3389/fcvm.2022.818275] [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: 11/19/2021] [Accepted: 01/17/2022] [Indexed: 11/22/2022] Open
Abstract
A 30-year-old man with an ECG demonstrating ventricular preexcitation with a normal PR interval and a QR pattern in lead V1 was evaluated. Electrophysiology studies showed a normal AH interval and a shortened HV interval at sinus rhythm; while the degree of preexcitation (QRS waveform) and HV interval were not affected by multisite or incremental atrial pacing. These findings implied ventricular preexcitation due to a fasciculoventricular pathway (FVP). Moreover, temporarily blocking FVP conduction mechanically resulted in normal HV interval, absence of delta wave, and an rSR pattern in V1, which indicated incomplete right bundle branch block (IRBBB). These findings suggested the coexistence of FVP and IRBBB, which is very rare.
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Bera D, Mukherjee SS, Kar A. Short HV interval in absence of delta wave and normal PR interval - what is the mechanism ? HeartRhythm Case Rep 2022; 8:383-386. [PMID: 35607337 PMCID: PMC9123312 DOI: 10.1016/j.hrcr.2022.01.018] [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: 11/28/2022] Open
Affiliation(s)
- Debabrata Bera
- Department of Cardiology, Rabindranath Tagore International Institute of Cardiac Sciences, Kolkata, India
- Address reprint requests and correspondence: Dr Debabrata Bera, Rabindranath Tagore International Institute of Cardiac Sciences (RTIICS), 124 Mukundapur, Kolkata, West Bengal, India, PIN 700099.
| | | | - Ayan Kar
- Department of Cardiology, Rabindranath Tagore International Institute of Cardiac Sciences, Kolkata, India
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Gormel S, Yasar S. Fasciculoventricular pathways-A rare and innocent variant: A Retrospective study focusing on clinical and electrophysiologic characteristics. Ann Noninvasive Electrocardiol 2022; 27:e12913. [PMID: 34974635 PMCID: PMC9107080 DOI: 10.1111/anec.12913] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 11/08/2021] [Accepted: 11/09/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Fasciculoventricular pathways (FVPs) are variants of pre-excitation syndrome which were investigated insufficiently because of its rarity. OBJECTIVE This report aimed to represent one of the largest series of FVP, focusing on its clinical and electrophysiological properties. METHODS We analyzed retrospectively 26 consecutive patients who underwent electrophysiological study (EPS) for FVP between January 1998 and June 2020. RESULTS Among 1437 patients with accessory pathways, 26 had FVP (1.80%). All the 26 patients (100%) were males, with a mean age of 22.15 ± 3.50 years (range, 20-34 years). In the baseline electrocardiograms of the patients with FVP, pre-excitation and transitional zone were seen in leads V2 -V4 . During EPS procedures, normal AH interval and shortened HV interval were detected. All the patients had AH prolongation after atrial pacing due to atrioventricular (AV) nodal delay without change in pre-excitation degree. Five of the FVP patients (19.2%) had extra accessory pathways, all of which were ablated successfully while the FVPs were followed clinically. CONCLUSION Fasciculoventricular pathways are uncommon variants of pre-excitation syndrome; therefore, they should be diagnosed correctly and followed up noninvasively to avoid damages.
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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
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Jiménez JR, Rajjoub Almahdi EA, Lozano Granero VC, Planas JM. Young patient with curious preexcitation: Ready to fly before catheters placement. Indian Pacing Electrophysiol J 2021; 21:251-254. [PMID: 34000370 PMCID: PMC8263329 DOI: 10.1016/j.ipej.2021.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 04/29/2021] [Accepted: 05/11/2021] [Indexed: 11/24/2022] Open
Affiliation(s)
- Javier Ramos Jiménez
- Cardiac Electrophysiology and Pacing Department, University Hospital Ramón y Cajal. Madrid, Spain.
| | | | | | - Javier Moreno Planas
- Cardiac Electrophysiology and Pacing Department, University Hospital Ramón y Cajal. Madrid, Spain
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Darden D, Hsu JC, Tzou WS, von Alvensleben JC, Brooks M, Hoffmayer KS, Brambatti M, Sauer WH, Feld GK, Adler E. Fasciculoventricular and atrioventricular accessory pathways in patients with Danon disease and preexcitation: A multicenter experience. Heart Rhythm 2021; 18:1194-1202. [PMID: 33737230 DOI: 10.1016/j.hrthm.2021.03.024] [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: 10/25/2020] [Revised: 02/23/2021] [Accepted: 03/11/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Studies have suggested that a fasciculoventricular pathway (FVP) may be the cause of preexcitation in patients with Danon disease, a rare X-linked dominant genetic disorder of hypertrophic cardiomyopathy. OBJECTIVE The purpose of this study was to describe the prevalence of ventricular preexcitation on resting 12-lead electrocardiogram (ECG) in patients with Danon disease and the electrophysiological study (EPS) results of those with preexcitation. METHODS Patients with confirmed Danon disease diagnosed with preexcitation (PR ≤120 ms, delta wave, QRS >110 ms) on ECG were included from a multicenter registry. The incidence of arrhythmias, implantable cardioverter-defibrillator (ICD) procedures, ICD shocks, and EPS results were collected. RESULTS Thirteen of 40 patients (32.5%) with Danon disease were found to have preexcitation (mean age 17.3 years; 38% women). EPS performed in 9 of 13 patients (69%) demonstrated FVP only in 2 (22.2%), extranodal pathway without exclusion of FVP in 2 (22.2%), and both FVP and extranodal pathway in 5 (55.6%). Two patients had malignant accessory pathway (AP) properties. Over median follow-up of 842 days (interquartile range 138-1678), 11 patients (85%) had ICD placement, and 6 (46.1%) underwent heart transplantation. No patients required therapy for ventricular tachycardia, and 2 patients (15%) had paroxysmal atrial fibrillation. CONCLUSION In a large multicenter cohort of patients with Danon disease, there was a high prevalence of FVP and extranodal pathways diagnosed on EPS in those with preexcitation. These findings suggest patients with preexcitation and Danon disease should undergo EPS to assess for FVP and potentially malignant extranodal AP.
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Affiliation(s)
- Douglas Darden
- Division of Cardiology, Department of Medicine, University of California, San Diego, La Jolla, California.
| | - Jonathan C Hsu
- Division of Cardiology, Department of Medicine, University of California, San Diego, La Jolla, California
| | - Wendy S Tzou
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Johannes C von Alvensleben
- Division of Cardiology, Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Aurora, Colorado
| | - Mary Brooks
- Division of Cardiology, Department of Medicine, University of California, San Diego, La Jolla, California
| | - Kurt S Hoffmayer
- Division of Cardiology, Department of Medicine, University of California, San Diego, La Jolla, California
| | - Michela Brambatti
- Division of Cardiology, Department of Medicine, University of California, San Diego, La Jolla, California
| | - William H Sauer
- Division of Cardiology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Gregory K Feld
- Division of Cardiology, Department of Medicine, University of California, San Diego, La Jolla, California
| | - Eric Adler
- Division of Cardiology, Department of Medicine, University of California, San Diego, La Jolla, California
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Bagliani G, De Ponti R, Sciarra L, Zingarini G, Leonelli FM. Accessory Pathway-Mediated Tachycardias: Precision Electrocardiology Through Standard and Advanced Electrocardiogram Recording Techniques. Card Electrophysiol Clin 2020; 12:475-493. [PMID: 33161997 DOI: 10.1016/j.ccep.2020.08.008] [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
An accessory pathway (AP) can be apparent during sinus rhythm if it depolarizes part of the ventricles ahead of the normal wave front from the conduction system. An AP can generate an anatomic circuit able to sustain a macroreentrant atrioventricular reentrant tachycardia. This arrhythmia can engage the normal conducting system in an antegrade direction or retrogradely, generating, respectively, a narrow or a wide complex tachycardia. The combined use of a standard electrocardiogram and an esophageal recording-pacing can be particularly useful in the first approach to patients with Wolff-Parkinson-White syndrome, further stratifying patients requiring electrophysiology study and transcatheter ablation.
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Affiliation(s)
- Giuseppe Bagliani
- Arrhythmology Unit, Cardiology Department, Foligno General Hospital, Via Massimo Arcamone, Foligno, Perugia 06034, Italy; Cardiovascular Disease Department, University of Perugia, Piazza Menghini 1, Perugia 06129, Italy; Arrhythmology and Electrophysiology Department, IRCCS Policlinico San Donato, San Donato Milanese, Milano, 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
| | - Luigi Sciarra
- Cardiology Unit, Policlinico Casilino, Via Casilina 1049, Rome 00169, Italy
| | - Gianluca Zingarini
- Cardiovascular Disease Department, University of Perugia, Piazza Menghini 1, Perugia 06129, Italy
| | - Fabio M Leonelli
- Cardiology Department, James A. Haley Veterans' Hospital, 13000 Bruce B Down Boulevard, Tampa, FL 33612, USA; University of South Florida, 4202 East Fowler Avenue, Tampa, FL 33620, USA
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12
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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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Nagashima K, Wakamatsu Y, Kurokawa S, Otsuka N, Yagyu S, Okumura Y. Minimally preexcited tachycardia: What is the mechanism? HeartRhythm Case Rep 2020; 6:805-807. [PMID: 33101961 PMCID: PMC7573369 DOI: 10.1016/j.hrcr.2020.07.001] [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: 11/30/2022] Open
Affiliation(s)
- Koichi Nagashima
- Address reprint requests and correspondence: Dr Koichi Nagashima, Division of Cardiology, Department of Medicine, Nihon University School of Medicine, 30-1 Ohyaguchi-kamicho, Itabashi-ku, Tokyo 173-8610, Japan.
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Arias MA, Pachón M, Martín‐Sierra C. Isolated palpitations and ventricular pre-excitation. J Arrhythm 2020; 36:794-796. [PMID: 32782659 PMCID: PMC7411198 DOI: 10.1002/joa3.12358] [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: 03/26/2020] [Revised: 04/20/2020] [Accepted: 04/27/2020] [Indexed: 11/20/2022] Open
Abstract
A 27-year-old male was referred for further assessment after being evaluated by his general practitioner for isolated palpitations. A twelve-lead electrocardiogram was performed in which sinus rhythm with ventricular pre-excitation were observed. Electrophysiologic study demonstrated the presence of a fasciculoventricular accessory pathway.
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Affiliation(s)
- Miguel A. Arias
- Arrhythmia UnitDepartment of CardiologyComplejo Hospitalario Universitario de ToledoToledoSpain
| | - Marta Pachón
- Arrhythmia UnitDepartment of CardiologyComplejo Hospitalario Universitario de ToledoToledoSpain
| | - Cristina Martín‐Sierra
- Arrhythmia UnitDepartment of CardiologyComplejo Hospitalario Universitario de ToledoToledoSpain
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15
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Asvestas D, Bazoukis G, Mililis P, Dragasis S, Megarisiotou A, Vlachos K, Sideris A, Efremidis M, Letsas KP. Fasciculoventricular bypass tracts: Electrocardiographic and electrophysiologic features. J Arrhythm 2020; 36:537-541. [PMID: 32528586 PMCID: PMC7279985 DOI: 10.1002/joa3.12355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 04/12/2020] [Accepted: 04/16/2020] [Indexed: 12/13/2022] Open
Abstract
Fasciculoventricular accessory pathways are rare variants of preexcitation. The differential diagnosis of fasciculoventricular accessory pathways from other preexcitation variants can be challenging. Based on two cases, we discuss the specific electrocardiographic and electrophysiologic features of fasciculoventricular bypass tracts.
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Affiliation(s)
- Dimitrios Asvestas
- Arrhythmia Unit Laboratory of Cardiac Electrophysiology "Evangelismos" General Hospital of Athens Athens Greece
| | - George Bazoukis
- Arrhythmia Unit Laboratory of Cardiac Electrophysiology "Evangelismos" General Hospital of Athens Athens Greece
| | - Panagiotis Mililis
- Arrhythmia Unit Laboratory of Cardiac Electrophysiology "Evangelismos" General Hospital of Athens Athens Greece
| | - Stelios Dragasis
- Arrhythmia Unit Laboratory of Cardiac Electrophysiology "Evangelismos" General Hospital of Athens Athens Greece
| | - Athanasia Megarisiotou
- Arrhythmia Unit Laboratory of Cardiac Electrophysiology "Evangelismos" General Hospital of Athens Athens Greece
| | - Konstantinos Vlachos
- Arrhythmia Unit Laboratory of Cardiac Electrophysiology "Evangelismos" General Hospital of Athens Athens Greece
| | - Antonios Sideris
- Arrhythmia Unit Laboratory of Cardiac Electrophysiology "Evangelismos" General Hospital of Athens Athens Greece
| | - Michael Efremidis
- Arrhythmia Unit Laboratory of Cardiac Electrophysiology "Evangelismos" General Hospital of Athens Athens Greece
| | - Konstantinos P Letsas
- Arrhythmia Unit Laboratory of Cardiac Electrophysiology "Evangelismos" General Hospital of Athens Athens Greece
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16
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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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17
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Chubb H, Ceresnak SR. A proposed approach to the asymptomatic pediatric patient with Wolff-Parkinson-White pattern. HeartRhythm Case Rep 2020; 6:2-7. [PMID: 31956492 PMCID: PMC6962761 DOI: 10.1016/j.hrcr.2019.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 09/01/2019] [Accepted: 09/05/2019] [Indexed: 01/02/2023] Open
Affiliation(s)
| | - Scott R. Ceresnak
- Address reprint requests and correspondence: Dr Scott R. Ceresnak, Department of Pediatrics - Division of Pediatric Cardiology, 750 Welch Rd, Suite 305, Palo Alto, CA 94304.
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18
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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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19
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Fasciculoventricular accessory pathway unmasked by a pseudo gap phenomenon. J Electrocardiol 2019; 55:41-44. [DOI: 10.1016/j.jelectrocard.2019.04.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 04/15/2019] [Accepted: 04/30/2019] [Indexed: 11/20/2022]
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