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Austin KM, Alexander ME, Triedman JK. Pediatric T-wave memory after accessory pathway ablation in Wolff-Parkinson-White syndrome. Heart Rhythm 2022; 19:459-465. [PMID: 34767987 PMCID: PMC9026902 DOI: 10.1016/j.hrthm.2021.11.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 10/20/2021] [Accepted: 11/03/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Altered ventricular depolarization due to manifest accessory pathway conduction (ie, Wolff-Parkinson-White syndrome) leads to repolarization abnormalities that persist after pathway ablation. The term T-wave memory (TWM) has been applied to these changes, as the postablation T-wave vector "remembers" the pre-excited QRS vector. In adults, these abnormalities can be misinterpreted as ischemia leading to unnecessary interventions. To date, no comprehensive studies have evaluated this phenomenon in the pediatric population. OBJECTIVE The purpose of this study was to define TWM in the pediatric population, identify preablation risk factors, and delineate the timeline of recovery. METHODS Pre- and postablation electrocardiograms (ECGs) in patients ≤25 years were analyzed over a 5-year period. Frontal plane QTc interval, T-wave axis, QRST angle, and T-wave inversions were used to identify patients with TWM. Univariate analysis was performed to determine the association of preablation ECG features with the outcome of TWM. RESULTS TWM was present in 42% of pediatric patients, with resolution occurring within 3 months of ablation. Preablation QRS axis <0° was a strong predictor of TWM (odds ratio [OR] 15.2; 95% confidence interval [CI] 5.7-40), followed by posteroseptal pathway location (right posteroseptal-OR 8.9; 95% CI 4.2-18.8; left posteroseptal-OR 6.1; 95% CI 1.7-22.3). The degree of pre-excitation had a modest association with the development of TWM. No adverse events were observed. CONCLUSION TWM is less common in children compared to adults, and normalization occurred within 3 months postablation. The most predictive features for the development of TWM include a leftward pre-excited QRS axis and posteroseptal pathway location.
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Affiliation(s)
- Karyn M Austin
- Arrhythmia Service, Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.
| | - Mark E Alexander
- Arrhythmia Service, Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - John K Triedman
- Arrhythmia Service, Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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Kichloo A, Haji AQ, Kanjwal K. Cardiac memory presenting as ST elevations following premature ventricular complex ablation. HeartRhythm Case Rep 2020; 7:52-55. [PMID: 33505856 PMCID: PMC7813796 DOI: 10.1016/j.hrcr.2020.10.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Asim Kichloo
- Department of Internal Medicine, Samaritan Medical Center, Watertown, New York
- Department of Internal Medicine, Central Michigan University, Saginaw, Michigan
| | - Abdul Qadir Haji
- Department of Cardiology, Martinsburg VA Medical Center, Martinsburg, West Virginia
| | - Khalil Kanjwal
- Department of Electrophysiology, McLaren Greater Lansing Hospital, Lansing, Michigan
- Address reprint requests and correspondence: Dr Khalil Kanjwal, Clinical Associate Professor of Medicine, Michigan State University, McLaren Greater Lansing Hospital, Lansing, MI 48901.
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Abstract
Cardiac memory (CM) is a commonly unrecognized entity in which electrocardiograph (EKG) changes demonstrate T wave inversions (TWI) that appear consistent with ischemia. Inability to recognize and distinguish CM from actual ischemia can be a burden for both patients and hospitals, leading to unnecessary hospital admission, cardiac testing, and cardiac catheterization. Simple EKG analysis and meticulous interpretation of T-wave axis and morphology can help differentiate between the two. We present a case with such a dilemma, and an overview literature and physiology behind this entity.
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Affiliation(s)
- Rastko Rakočević
- Internal Medicine, University Hospital - Rutgers New Jersey Medical School, Newark, USA.,Pulmonary and Critical Care Medicine, University of Southern California, Los Angeles, USA
| | - Renjit Thomas
- Cardiology, University Hospital - Rutgers New Jersey Medical School, Newark, USA
| | - Ralph G Oriscello
- Cardiology/Critical Care, Veterans Affairs (VA) East Orange/Rutgers New Jersey Medical School, East Orange, USA
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Grimm W, Luck K, Greene B, Parahuleva M. [Cardiac memory following pacemaker implantation]. Herzschrittmacherther Elektrophysiol 2019; 30:404-408. [PMID: 31562545 DOI: 10.1007/s00399-019-00646-x] [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: 08/16/2019] [Accepted: 09/05/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Although T wave inversions due to cardiac memory were described already 50 years ago, little is known about the prevalence and about clinical predictors of this phenomenon. METHODS After exclusion of 238 patients due to bundle branch block or pacemaker dependency, a total of 325 consecutive patients were enrolled in this study during routine outpatient control of their pacemaker. A 12-lead standard ECG was obtained in all patients during transient inhibition of pacing therapy. RESULTS Cardiac memory could be documented in 115 of 325 patients (35%) and showed a strong association with the amount of ventricular stimulation. The prevalence of cardiac memory was 9% in patients with ≤25% ventricular stimulation and 86% in patients with ≥75% ventricular stimulation. DISCUSSION Cardiac memory was observed in one third of patients following pacemaker implantation. The prevalence of cardiac memory in the ECG with intrinsic rhythm is above 80% in patients with frequent ventricular stimulation. Cardiac memory due to ventricular stimulation is benign and should not be confused with similar T wave inversions due to acute coronary syndrome, severe left ventricular hypertrophy, or myocarditis.
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Affiliation(s)
- Wolfram Grimm
- Universitätsklinik Marburg, Klinik für Innere Medizin - Kardiologie, Angiologie und Intensivmedizin, UKGM Gießen und Marburg, Standort Marburg, Baldingerstraße, 35033, Marburg, Deutschland.
| | - Kathrin Luck
- Universitätsklinik Marburg, Klinik für Innere Medizin - Kardiologie, Angiologie und Intensivmedizin, UKGM Gießen und Marburg, Standort Marburg, Baldingerstraße, 35033, Marburg, Deutschland
| | - Brandon Greene
- Institut für Medizinische Bioinformatik und Biostatistik, Philipps Universität Marburg., Marburg, Deutschland
| | - Mariana Parahuleva
- Universitätsklinik Marburg, Klinik für Innere Medizin - Kardiologie, Angiologie und Intensivmedizin, UKGM Gießen und Marburg, Standort Marburg, Baldingerstraße, 35033, Marburg, Deutschland
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Wecke L, Poçi D, Schwieler J, Johansson B, Edvardsson N, Lundahl G, Bergfeldt L. Vectorcardiography shows cardiac memory and repolarization heterogeneity after ablation of accessory pathways not apparent on ECG. Int J Cardiol 2013; 166:152-7. [DOI: 10.1016/j.ijcard.2011.10.106] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2011] [Revised: 09/06/2011] [Accepted: 10/18/2011] [Indexed: 11/28/2022]
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Pavri BB, Hillis MB, Subacius H, Brumberg GE, Schaechter A, Levine JH, Kadish A. Prognostic value and temporal behavior of the planar QRS-T angle in patients with nonischemic cardiomyopathy. Circulation 2008; 117:3181-6. [PMID: 18574059 DOI: 10.1161/circulationaha.107.733451] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The planar QRS-T angle can be easily obtained from standard 12-lead ECGs, but its predictive ability is not established. We sought to determine the predictive ability of the planar QRS-T angle in patients with nonischemic cardiomyopathy and to assess QRS-T angle behavior over time. METHODS AND RESULTS Baseline QRS-T angles from 455 patients in the Defibrillators in Nonischemic Cardiomyopathy Treatment Evaluation (DEFINITE) trial were measured. All patients had nonischemic cardiomyopathy, New York Heart Association class I to III heart failure, and nonsustained ventricular tachycardia or frequent ventricular ectopy. The primary end point (a composite of total mortality, appropriate implantable cardioverter-defibrillator shock, or resuscitated cardiac arrest) occurred in 25 of 172 patients (14.5%) with a QRS-T angle < or =90 degrees and in 72 of 283 patients (25.4%) with a QRS-T angle >90 degrees (hazard ratio, 1.93; 95% confidence interval, 1.23 to 3.05; P=0.002). A QRS-T angle >90 degrees remained a significant predictor of the primary end point (P=0.039) after adjustment for treatment group, age, gender, QRS duration, left bundle-branch block, left ventricular ejection fraction, New York Heart Association class III, atrial fibrillation, and diabetes mellitus. The secondary end point (total mortality) occurred in 17 of the 172 patients (9.9%) with a QRS-T angle < or =90 degrees and in 49 of the 283 patients (17.3%) with a QRS-T angle >90 degrees (hazard ratio, 1.79; 95% confidence interval, 1.03 to 3.10; P=0.016). A sample of 152 patients with multiple follow-up ECGs was analyzed to assess temporal QRS-T angle behavior. Changes in the QRS-T angle correlated with changes in left ventricular ejection fraction and QRS duration over time (P<0.001). CONCLUSIONS A planar QRS-T angle >90 degrees is a significant predictor of a composite end point of death, appropriate implantable cardioverter-defibrillator shock, or resuscitated cardiac arrest in nonpaced, mild to moderately symptomatic patients with nonischemic cardiomyopathy with frequent or complex ventricular ectopy. QRS-T angles changed predictably with left ventricular ejection fraction and QRS duration.
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Affiliation(s)
- Behzad B Pavri
- Department of Medicine, Division of Cardiology, Thomas Jefferson University Hospital, 925 Chestnut St, Philadelphia, PA 19107, USA.
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Ghosh S, Rhee EK, Avari JN, Woodard PK, Rudy Y. Cardiac memory in patients with Wolff-Parkinson-White syndrome: noninvasive imaging of activation and repolarization before and after catheter ablation. Circulation 2008; 118:907-15. [PMID: 18697818 DOI: 10.1161/circulationaha.108.781658] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Cardiac memory refers to a change in ventricular repolarization induced by and persisting for minutes to months after cessation of a period of altered ventricular activation (eg, resulting from pacing or preexcitation in patients with Wolff-Parkinson-White syndrome). ECG imaging (ECGI) is a novel imaging modality for noninvasive electroanatomic mapping of epicardial activation and repolarization. METHODS AND RESULTS Fourteen pediatric patients with Wolff-Parkinson-White syndrome and no other congenital disease, were imaged with ECGI a day before and 45 minutes, 1 week, and 1 month after successful catheter ablation. ECGI determined that preexcitation sites were consistent with sites of successful ablation in all cases to within a 1-hour arc of each atrioventricular annulus. In the preexcited rhythm, activation-recovery interval (ARI) was the longest (349+/-6 ms) in the area of preexcitation leading to high average base-to-apex ARI dispersion of 95+/-9 ms (normal is approximately 40 ms). The ARI dispersion remained the same 45 minutes after ablation, although the activation sequence was restored to normal. ARI dispersion was still high (79+/-9 ms) 1 week later and returned to normal (45+/-6 ms) 1 month after ablation. CONCLUSIONS The study demonstrates that ECGI can noninvasively localize ventricular insertion sites of accessory pathways to guide ablation and evaluate its outcome in pediatric patients with Wolff-Parkinson-White syndrome. Wolff-Parkinson-White is associated with high ARI dispersion in the preexcited rhythm that persists after ablation and gradually returns to normal over a period of 1 month, demonstrating the presence of cardiac memory. The 1-month time course is consistent with transcriptional reprogramming and remodeling of ion channels.
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Affiliation(s)
- Subham Ghosh
- Cardiac Bioelectricity and Arrhythmia Center, Department of Biomedical Engineering, Washington University, St Louis, MO, USA
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Aunes-Jansson M, Wecke L, Lurje L, Bergfeldt L, Edvardsson N. T wave inversions following ablation of 125 posteroseptal accessory pathways. Int J Cardiol 2006; 106:75-81. [PMID: 16321670 DOI: 10.1016/j.ijcard.2004.12.094] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2004] [Accepted: 12/31/2004] [Indexed: 11/19/2022]
Abstract
BACKGROUND Cardiac memory, electrophysiological remodeling induced by periods of altered ventricular activation, has been observed after resumption of normal activation following ablation of overt accessory pathways. We studied the occurrence and temporal characteristics of cardiac memory (inferior T wave inversions) after ablation of overt posteroseptal accessory pathways. METHODS T wave changes were assessed in the frontal plane (leads II, aVF, and III) up to one year after the ablation in 125 consecutive patients. T wave polarity immediately after ablation was compared with the pre ablation delta wave polarity and the dominant QRS force in each lead. The number of inferior leads (0-3) with post ablation T wave changes (estimate of degree of cardiac memory) was analyzed in relation to estimates of the degree of preexcitation (accessory pathway refractoriness and QRS duration) prior to ablation. RESULTS Electrocardiogram (ECG) signs of cardiac memory were present in 123 (98%) of the patients within one day after ablation. The post ablation T wave vector had the same direction as the vector of the pre-excited QRS complex (and delta wave) creating inferior T wave inversions. There was no correlation between the degree of preexcitation pre ablation and the extent of cardiac memory post ablation. A majority (about 90%) of ECGs recorded 3-6 months after the procedure, showed complete or almost complete normalization. CONCLUSIONS T wave inversions were present in the vast majority of patients, persisted in some patients beyond 3 months, and might be misinterpreted as inferior wall ischemia.
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Affiliation(s)
- Maria Aunes-Jansson
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
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Shvilkin A, Ho KKL, Rosen MR, Josephson ME. T-vector direction differentiates postpacing from ischemic T-wave inversion in precordial leads. Circulation 2005; 111:969-74. [PMID: 15710753 DOI: 10.1161/01.cir.0000156463.51021.07] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Postpacing precordial T-wave inversion (TWI), known as cardiac memory (CM), mimics ischemic precordial TWI, and there are no established ECG criteria that adequately distinguish between the two. On the basis of CM properties (postpacing sinus rhythm T vector approaching the direction of the paced QRS vector), we hypothesized that CM induced by right ventricular pacing would manifest a TWI pattern different from that of precordial ischemic TWI, thereby discriminating between the two. METHODS AND RESULTS T-wave axis, polarity, and amplitude on a 12-lead ECG during sinus rhythm were compared between CM and ischemic patients. The CM group incorporated 13 patients who were paced in DDD mode with short atrioventricular delay for 1 week after elective pacemaker implantation. The ischemic group consisted of 47 patients with precordial TWI identified among 228 consecutive patients undergoing percutaneous coronary intervention for an acute coronary syndrome. The combination of (1) positive T(aVL), (2) positive or isoelectric T(I), and (3) maximal precordial TWI>TWI(III) was 92% sensitive and 100% specific for CM, discriminating it from ischemic precordial TWI. CONCLUSIONS CM induced by right ventricular pacing results in a distinctive T-vector pattern that allows discrimination from ischemic precordial T-wave inversions regardless of the coronary artery involved.
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Affiliation(s)
- Alexei Shvilkin
- Beth Israel Deaconess Medical Center, Boston, Mass 02215, USA
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Herweg B, Weiner S, Ilercil A, Polosajian L, Ferrick KJ, Fisher JD. Cardiac memory, a surface electrocardiographic clue in the differential diagnosis of ongoing narrow complex tachycardia. Am J Cardiol 2002; 90:428-31. [PMID: 12161238 DOI: 10.1016/s0002-9149(02)02505-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Bengt Herweg
- St. Luke's Roosevelt Hospital Center and Columbia University, New York, New York, USA
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