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Steinfurt J, Gressler A, Stuplich J, Jordan E, Jäckel M, Gjermeni D, Eichenlaub M, Bohnen M, Luik A, Jadidi A, Faber TS, Stiller B, Westermann D, Arentz T, Lehrmann H, Fedorov D. Impact of high-resolution 3D-mapping with micro-electrodes on catheter ablation of Wolff-Parkinson-White syndrome. IJC HEART & VASCULATURE 2024; 53:101435. [PMID: 38946712 PMCID: PMC11214477 DOI: 10.1016/j.ijcha.2024.101435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Revised: 05/12/2024] [Accepted: 05/27/2024] [Indexed: 07/02/2024]
Abstract
Background It is currently unknown whether high-resolution 3D-mapping and micro-electrodes add meaningful benefits in catheter ablation of Wolff-Parkinson-White (WPW) syndrome and challenging, e.g. para-Hisian accessory pathways (APs). Objectives To compare the mapping resolution, acute success and complication rates in patients with WPW syndrome undergoing a first-time catheter ablation using only a contact force-sensing ablation catheter for mapping or a multi-electrode high-resolution mapping catheter. Methods Fifty consecutive 3D-mapping procedures for WPW syndrome using a 3.5-mm ablation catheter (n = 27) or a multi-electrode high-resolution catheter (n = 23) were retrospectively analyzed regarding mapping resolution defined as first 5/10 msec isochronal activation area, number of RF applications to achieve AP block, occurence of AP automaticity during RF delivery, and acute success and complication rates. Results Catheter ablation was successful in 48/50 patients with a median of 1 (IQR 1-2) RF applications. Compared to ablation catheter mapping, high-resolution mapping showed a significantly smaller isochronal activation area in the first 5/10 msec (1.25 ± 0.29 vs 0.15 ± 0.03 cm2; P < 0.001 and 3.41 ± 0.58 vs 0.55 ± 0.12 cm2; P < 0.0001) and significantly higher incidence of AP automaticity during RF delivery (0 vs 22 %; P < 0.05). In para-Hisian APs, micro-electrodes recorded distinct His electrograms and AP potentials without fusion and without AP bumping permitting safe and effective para-Hisian AP ablation. Conclusions High-resolution mapping increases the mapping accuracy of the AP and its insertion site leading to a significantly higher incidence of AP automaticity during RF delivery. Micro-electrodes provide clinically relevant advantages in para-hisian AP mapping improving efficacy and safety of para-Hisian AP ablation.
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Affiliation(s)
- Johannes Steinfurt
- Department of Cardiology and Angiology, University Heart Center Freiburg – Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Alexander Gressler
- Department of Cardiology and Angiology, University Heart Center Freiburg – Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Judith Stuplich
- Department of Cardiology and Angiology, University Heart Center Freiburg – Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Eike Jordan
- Department of Cardiology and Angiology, University Heart Center Freiburg – Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Markus Jäckel
- Department of Cardiology and Angiology, University Heart Center Freiburg – Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Diona Gjermeni
- Department of Cardiology and Angiology, University Heart Center Freiburg – Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Martin Eichenlaub
- Department of Cardiology and Angiology, University Heart Center Freiburg – Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Marius Bohnen
- Department of Cardiology and Angiology, University Heart Center Freiburg – Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Armin Luik
- Medizinische Klinik IV at Städtisches Klinikum Karlsruhe, Academic Teaching Hospital of the University of Freiburg, Germany
| | - Amir Jadidi
- Department of Cardiology and Angiology, University Heart Center Freiburg – Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Thomas S. Faber
- Department of Cardiology and Angiology, University Heart Center Freiburg – Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Brigitte Stiller
- Department of Pediatric Cardiology, University Heart Center Freiburg – Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Dirk Westermann
- Department of Cardiology and Angiology, University Heart Center Freiburg – Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Thomas Arentz
- Department of Cardiology and Angiology, University Heart Center Freiburg – Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Heiko Lehrmann
- Department of Cardiology and Angiology, University Heart Center Freiburg – Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Denis Fedorov
- Department of Cardiology and Angiology, University Heart Center Freiburg – Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Dos Santos Sousa IB, Chokr MO, Melo SL, Pisani CF, Hardy CA, de Moura LG, Sacilotto L, Wu TC, Darrieux FCC, Scanavacca MI. Comparison between cryotherapy and radiofrequency energy sources for parahisian accessory pathway percutaneous ablation. J Interv Card Electrophysiol 2024:10.1007/s10840-024-01841-8. [PMID: 38833098 DOI: 10.1007/s10840-024-01841-8] [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: 02/29/2024] [Accepted: 05/28/2024] [Indexed: 06/06/2024]
Abstract
BACKGROUND Catheter ablation of parahisian accessory pathways (PHAP) are challenging due to their proximity to the normal conduction system. Retrospective studies suggest that cryoablation has a better safety profile but a higher recurrence rate when compared to radiofrequency ablation (RFCA). The objective of this study was to compare the results of parahisian AP ablation performed by electrophysiologists with experience in both technologies. METHODS Prospective single-center, non-blinded and 1:1 model was used. Patients included had parahisian AP confirmed by an electrophysiological study and referred for radiofrequency or cryotherapy ablation according to current guidelines, under fluoroscopic guidance. No electroanatomic mapping was used. RESULTS A total of 30 patients (mean age of 25±9.4 years; 90% male) were enrolled between Oct/2018 to Feb/2020. Acute success rate between RFCA and CRYO were similar (93% vs. 87%, p = 0.54). A nonsignificant reduction in short-term recurrence rate for RFCA (14% vs. 30%, p = 0.3) and mechanical trauma (6% vs. 20%; p = 0.28) was observed. Long-term recurrence rate and event-free survival time were similar in both groups after 1-year follow-up (p = 0.286). No persistent complete AV block or conduction disturbance was also observed. CONCLUSION Considering the limitation of a small sample size and the lack of use of electroanatomic mapping for RFCA, the efficacy and safety profile of parahisian AP ablation with RFCA was not different from CRYO, when performed by experienced electrophysiologists. No cases of permanent complete AV block were reported with either energy modalities.
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Affiliation(s)
- Italo Bruno Dos Santos Sousa
- Cardiac Arrhythmia Unit, Heart Institute (InCor), University of Sao Paulo Medical School, Sao Paulo, SP, Brazil.
| | - Muhieddine Omar Chokr
- Cardiac Arrhythmia Unit, Heart Institute (InCor), University of Sao Paulo Medical School, Sao Paulo, SP, Brazil
| | - Sissy Lara Melo
- Cardiac Arrhythmia Unit, Heart Institute (InCor), University of Sao Paulo Medical School, Sao Paulo, SP, Brazil
| | - Cristiano Faria Pisani
- Cardiac Arrhythmia Unit, Heart Institute (InCor), University of Sao Paulo Medical School, Sao Paulo, SP, Brazil
| | - Carina Abigail Hardy
- Cardiac Arrhythmia Unit, Heart Institute (InCor), University of Sao Paulo Medical School, Sao Paulo, SP, Brazil
| | - Lucas Goyanna de Moura
- Cardiac Arrhythmia Unit, Heart Institute (InCor), University of Sao Paulo Medical School, Sao Paulo, SP, Brazil
| | - Luciana Sacilotto
- Cardiac Arrhythmia Unit, Heart Institute (InCor), University of Sao Paulo Medical School, Sao Paulo, SP, Brazil
| | - Tan Chen Wu
- Cardiac Arrhythmia Unit, Heart Institute (InCor), University of Sao Paulo Medical School, Sao Paulo, SP, Brazil
| | | | - Mauricio Ibrahim Scanavacca
- Cardiac Arrhythmia Unit, Heart Institute (InCor), University of Sao Paulo Medical School, Sao Paulo, SP, Brazil
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Aydemir MM, Kafali HC, Ergul Y. A challenging catheter ablation of anteroseptal manifest accessory pathway from non-coronary aortic cusp in a paediatric patient. Cardiol Young 2023; 33:1474-1476. [PMID: 36660903 DOI: 10.1017/s1047951123000045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Twelve-lead ECG of a child with Wolff-Parkinson-White syndrome and systolic dysfunction was consistent with the anteroseptal accessory pathway. The earliest atrial activation during electrophysiological study was found between the right anteroseptal region near the HIS. Multiple femoral tract right-sided cryotest lesions followed by radiofrequency catheter irrigated through the jugular vein route were unsuccessful. Then, non-coronary aortic cusp mapping and cryoablation were successfully performed with a retroartic approach.
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Affiliation(s)
- Merve Maze Aydemir
- Department of Pediatric Cardiology, University of Health Sciences, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Hasan Candas Kafali
- Department of Pediatric Cardiology, University of Health Sciences, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Yakup Ergul
- Department of Pediatric Cardiology, University of Health Sciences, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
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Corcia MCG, Stuart G, Walsh M, Radulescu C, Spera F, Tijskens M, Heidbuchel H, Sarkozy A. Redo accessory pathway ablation in the pediatric population. J Interv Card Electrophysiol 2022; 63:639-649. [PMID: 34811627 PMCID: PMC9151527 DOI: 10.1007/s10840-021-01064-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 09/07/2021] [Indexed: 10/26/2022]
Abstract
BACKGROUND Literature reports 5% of recurrence/failure in paediatric accessory pathway ablations. Our aim was to investigate the reasons underlying this finding and share techniques to obtain long-term success. METHODS Thirty-nine paediatric patients referred for a repeat procedure were analysed: characteristics of the pathways and the initial and redo procedures were identified. RESULTS Mean age was 11.9 ± 3.3 years (59% males). Three patients (8%) had multiple accessory pathways. The most frequent location was left lateral (26%). Left sided pathway recurrence was caused mainly by poor contact (60%) and inadequate mapping (40%). For right lateral accessory pathways, poor contact accounted for 70% of failures. For antero-septal and para-Hisian locations, the use of cryoablation and choice of low radiofrequency energy delivery accounted for > 75% of failures. Long-term success strategies included choice of contact force catheters and radiofrequency applications at the ventricular insertion of the pathway and in the aortic coronary cusps. In postero-septal substrates, the main reason accounting for failure was deep or epicardial location of the pathway (37%), solved by using an irrigated tip catheter or applying lesions within the coronary sinus, or applications from both right and left postero-septal areas. CONCLUSION Acute failure and post-procedure recurrence in paediatric accessory pathway ablations have multiple reasons related to the characteristics of the pathway and the technology available. Accurate understanding of the anatomy, careful mapping and pacing manoeuvers, and incorporation of new technologies contribute to achieve a definitive success in > 98% of procedures.
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Affiliation(s)
- M Cecilia Gonzalez Corcia
- Department of Paediatric Cardiology, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Upper Maudlin Street, Bristol, BS2 8BJ, UK.
- Department of Cardiology, University Hospital Antwerp and University of Antwerp, Antwerp, Belgium.
| | - Graham Stuart
- Department of Paediatric Cardiology, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Upper Maudlin Street, Bristol, BS2 8BJ, UK
| | - Mark Walsh
- Department of Paediatric Cardiology, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Upper Maudlin Street, Bristol, BS2 8BJ, UK
| | - Cristina Radulescu
- Department of Paediatric Cardiology, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Upper Maudlin Street, Bristol, BS2 8BJ, UK
| | - Francesco Spera
- Department of Cardiology, University Hospital Antwerp and University of Antwerp, Antwerp, Belgium
| | - Maxime Tijskens
- Department of Cardiology, University Hospital Antwerp and University of Antwerp, Antwerp, Belgium
| | - Hein Heidbuchel
- Department of Cardiology, University Hospital Antwerp and University of Antwerp, Antwerp, Belgium
| | - Andrea Sarkozy
- Department of Cardiology, University Hospital Antwerp and University of Antwerp, Antwerp, Belgium
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Farré J, Anderson RH, Sánchez-Quintana D, Mori S, Rubio JM, García-Talavera C, Bansal R, Lokhandwala Y, Cabrera JA, Wellens HJJ, Sternick EB. Miniseries 2-septal and paraseptal accessory pathways-part II: para-Hisian accessory pathways-so-called anteroseptal pathways revisited. Europace 2022; 24:650-661. [PMID: 34999787 DOI: 10.1093/europace/euab293] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 11/08/2021] [Indexed: 11/12/2022] Open
Abstract
Surgeons, when dividing bypass tracts adjacent to the His bundle, considered them to be 'anteroseptal'. The area was subsequently recognized to be superior and paraseptal, although this description is not entirely accurate anatomically, and conveys little about the potential risk during catheter interventions. We now describe the area as being para-Hisian, and it harbours two types of accessory pathways. The first variant crosses the membranous septum to insert into the muscular ventricular septum without exiting the heart, and hence being truly septal. The second variant inserts distally in the paraseptal components of the supraventricular crest, and consequently is crestal. The site of ventricular insertion determines the electrocardiographic expression of pre-excitation during sinus rhythm, with the two types producing distinct patterns. In both instances, the QRS and the delta wave are positive in leads I, II, and aVF. In crestal pathways, however, the QRS is ≥ 140 ms, and exhibits an rS configuration in V1-2. The delta wave in V1-2 precedes by 20-50 ms the apparent onset of the QRS in I, II, III, and aVF. In the true septal pathways, the QRS complex occupies ∼120 ms, presenting a QS, W-shaped, morphology in V1-2. The delta wave has a simultaneous onset in all leads. Our proposed terminology facilitates the understanding of the electrocardiographic manifestations of both types of para-Hisian pathways during pre-excitation and orthodromic tachycardia, and informs on the level of risk during catheter ablation.
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Affiliation(s)
- Jerónimo Farré
- Fundación Jiménez Díaz University Hospital, Institute of Biomedical Research, Madrid, Spain
| | - Robert H Anderson
- Institute of Biosciences, Newcastle University, Newcastle upon Tyne, UK
| | | | - Shumpei Mori
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - José-Manuel Rubio
- Fundación Jiménez Díaz University Hospital, Institute of Biomedical Research, Madrid, Spain
| | - Camila García-Talavera
- Fundación Jiménez Díaz University Hospital, Institute of Biomedical Research, Madrid, Spain
| | - Raghav Bansal
- All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | | | - José-Angel Cabrera
- Unidad de Arritmias, Departamento de Cardiología, Hospital Universitario Quirón-Salud, Madrid, Spain.,Complejo Hospitalario Ruber Juan Bravo, Universidad Europea de Madrid, Madrid, Spain
| | - Hein J J Wellens
- CARIM-Cardiovascular Research Centre, Maastricht, The Netherlands
| | - Eduardo Back Sternick
- Arrhythmia and Electrophysiology Department, Biocor Instituto, Nova Lima, Minas Gerais, Brazil
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Wang F, Song X, Dang Y, Shu S, Li S. Successful ablation of a left anterior accessory pathway from the left coronary sinus of Valsalva near the aortic-mitral continuity. J Int Med Res 2021; 49:300060521990249. [PMID: 33682506 PMCID: PMC7944529 DOI: 10.1177/0300060521990249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Catheter ablation of accessory pathways can be challenging depending on the location of these pathways, and accessory pathways are rare through the aortic cusps. We report a patient who underwent radiofrequency catheter ablation for manifestation of a left anterior accessory pathway from the left coronary sinus of Valsalva near the aortic–mitral continuity. Anterior accessory pathways can be safely and effectively ablated from the aortic cusps with favorable long-term outcomes.
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Affiliation(s)
- Fan Wang
- Department of Cardiovascular Disease Center, Hebei General Hospital, Shijiazhuang, Hebei, China
| | - Xuelian Song
- Department of Cardiovascular Disease Center, Hebei General Hospital, Shijiazhuang, Hebei, China
| | - Yi Dang
- Department of Cardiovascular Disease Center, Hebei General Hospital, Shijiazhuang, Hebei, China
| | - Shangzhi Shu
- Department of Cardiovascular Disease Center, First Hospital of Jilin University, Jilin University, Jilin, China
| | - Shuyan Li
- Department of Cardiovascular Disease Center, First Hospital of Jilin University, Jilin University, Jilin, China
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Sandhu A, Tzou WS, Borne RT, Zipse MM, Nguyen DT, Sauer WH. Uncovering a unique path: Antidromic AVRT utilizing a left anteroseptal Mahaim-like accessory pathway. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2020; 44:185-188. [PMID: 32794265 DOI: 10.1111/pace.14024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 07/17/2020] [Accepted: 07/26/2020] [Indexed: 11/27/2022]
Abstract
A 40-year-old man presented to our emergency department 2 hours after onset of shortness of breath, palpitations, and presyncope secondary to an adenosine-responsive wide complex tachycardia. Electrophysiology study was diagnostic for antidromic atrioventricular (AV) reentrant tachycardia utilizing a muscular connection from the anterior interventricular vein to the left ventricle with Mahaim-like properties, successfully treated with ablation in the distal coronary sinus (CS) system. This case highlights accessory pathways (a) with unique features (i.e., Mahaim-like characteristics) and (b) involving musculature from the distal CS system, thereby limiting the value of endocardial ablation for durable treatment. Importantly, the coronary venous system is an accessible vascular network for evaluation and catheter ablation of such arrhythmias.
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Affiliation(s)
- Amneet Sandhu
- Section of Electrophysiology, The University of Colorado, Aurora, Colorado.,Section of Electrophysiology, Rocky Mountain Regional VA Medical Center, Aurora, Colorado
| | - Wendy S Tzou
- Section of Electrophysiology, The University of Colorado, Aurora, Colorado
| | - Ryan T Borne
- Section of Electrophysiology, The University of Colorado, Aurora, Colorado
| | - Matthew M Zipse
- Section of Electrophysiology, The University of Colorado, Aurora, Colorado
| | - Duy T Nguyen
- Section of Electrophysiology, Stanford University, Palo Alto, California
| | - William H Sauer
- Section of Electrophysiology, Brigham and Women's Hospital, Boston, Massachusetts
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Klaudel J, Trenkner W, Glaza M, Miekus P. Analysis of reported cases of left main coronary artery injury during catheter ablation: In search of a pattern. J Cardiovasc Electrophysiol 2019; 30:410-426. [DOI: 10.1111/jce.13833] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 12/03/2018] [Accepted: 12/18/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Jacek Klaudel
- Department of CardiologySt Vincent de Paul HospitalGdynia Poland
- Department of CardiologySt Adalbert's HospitalGdansk Poland
| | | | - Michal Glaza
- Department of CardiologySt Vincent de Paul HospitalGdynia Poland
| | - Pawel Miekus
- Department of CardiologySt Vincent de Paul HospitalGdynia Poland
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Verbeet T, Castro J, Almorad A. A recurrent concealed parahisian accessory pathway. Clin Case Rep 2018; 6:1101-1105. [PMID: 29881574 PMCID: PMC5985981 DOI: 10.1002/ccr3.1538] [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: 12/19/2017] [Revised: 03/03/2018] [Accepted: 03/24/2018] [Indexed: 11/17/2022] Open
Abstract
This case demonstrates the interest of ablating in the aortic root in case of resistant parahisian accessory pathways with failure of the right side approach. Failure on the right side may be due to fear of creating an AV block of failure to ablate critical fibers in the parahisian position.
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Affiliation(s)
- Thierry Verbeet
- Department of CardiologyCHU BrugmannFree University of Brussels4 Place Van Gehuchten1020BrusselsBelgium
| | - Jose Castro
- Department of CardiologyCHU BrugmannFree University of Brussels4 Place Van Gehuchten1020BrusselsBelgium
| | - Alexandre Almorad
- Department of CardiologyCHU BrugmannFree University of Brussels4 Place Van Gehuchten1020BrusselsBelgium
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