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Tednes P, Marquardt S, Kuhrau S, Heagler K, Rech M. Keeping It "Current": A Review of Treatment Options for the Management of Supraventricular Tachycardia. Ann Pharmacother 2024; 58:715-727. [PMID: 37743672 DOI: 10.1177/10600280231199136] [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] [Indexed: 09/26/2023] Open
Abstract
OBJECTIVE To review treatment options and updates that exist for the management of paroxysmal supraventricular tachycardia (PSVT). DATA SOURCES A literature search of PubMed was performed including articles from 1974 to June 2023 using the terms: arrhythmias, adenosine, verapamil, diltiazem, esmolol, propranolol, metoprolol, beta-blockers, amiodarone, PSVT, synchronized cardioversion, methylxanthines, dipyridamole, pediatrics, heart transplant, and pregnancy. Primary literature and guidelines were reviewed. STUDY SELECTION AND DATA EXTRACTION Studies were considered if they were available in English and conducted in humans. DATA SYNTHESIS PSVT is a subset of supraventricular tachycardia (SVT) that presents as a rapid, regular tachycardia with an abrupt onset and termination. Due to frequent emergency department (ED) visits annually with symptoms of PSVT, appropriate and efficient management of these patients is vital. This review provides an overview of the pathophysiology of PSVT, while also describing the literature behind nonpharmacologic and pharmacologic management of PSVT. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE This review describes new literature regarding the improved success of the modified Valsalva maneuver as a nonpharmacologic therapy in PSVT. In addition, it describes a new technique in administration of adenosine that has improved outcomes, defines dose adjustments needed for drug interactions with adenosine, compares the utilization of nondihydropyridine calcium channel blockers with adenosine, and provides management recommendations for patients in special populations. CONCLUSIONS With high annual rates of ED visits for SVT, providers should be aware of the data behind management and modifications of therapy based on patient-specific factors (ie, patient preference, pharmacokinetics/pharmacodynamics, drug interactions, and special populations).
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Affiliation(s)
- Patrick Tednes
- Department of Pharmacy, Ascension Resurrection Medical Center, Chicago, IL, USA
| | - Samantha Marquardt
- Department of Pharmacy, Ascension Resurrection Medical Center, Chicago, IL, USA
| | - Shannon Kuhrau
- Department of Pharmacy, Loyola University Medical Center, Maywood, IL, USA
| | - Kristin Heagler
- Department of Pharmacy, Loyola University Medical Center, Maywood, IL, USA
| | - Megan Rech
- Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. VA Hospital, Hines, IL, USA
- Department of Emergency Medicine, Stritch School of Medicine, Loyola University Chicago, Maywood, IL, USA
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2
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Baldi E, Sanzo A, Savastano S, Rordorf R. Ivabradine as a treatment option for junctional ectopic tachycardia in an adult female. Pacing Clin Electrophysiol 2024; 47:679-682. [PMID: 37650463 DOI: 10.1111/pace.14812] [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] [Received: 06/22/2023] [Revised: 08/08/2023] [Accepted: 08/20/2023] [Indexed: 09/01/2023]
Abstract
A Junctional ectopic tachycardia diagnosis was performed using two electrophysiological maneuvers in an adult female with a narrow-complex supraventricular tachycardia with a bystander AV-node slow pathway conduction, who previously underwent catheter ablation attempts for an atrio-ventricular nodal re-entrant tachycardia misdiagnosis. The first maneuver was atrial entrainment with an atrial-His-His-atrial response. The second was based on the response to a premature atrial complex delivered at different phases of the tachycardia cycle confirming that anterograde slow pathway conduction and retrograde fast pathway were not involved. Considering that verapamil, diltiazem, bisoprolol + flecainide, and nadolol were ineffective, we tried ivabradine with no sustained arrhythmias during 18-months.
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Affiliation(s)
- Enrico Baldi
- Arrhythmia and Electrophysiology Unit, Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Antonio Sanzo
- Arrhythmia and Electrophysiology Unit, Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Simone Savastano
- Arrhythmia and Electrophysiology Unit, Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Roberto Rordorf
- Arrhythmia and Electrophysiology Unit, Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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Kassa BD, Amede M, Wubante M, Libanos M, Geta K. Digoxin for the Management of Unstable Paroxysmal Supraventricular Tachycardia in a Patient Who Refused Electrical Cardioversion in a Rural Hospital. Case Rep Emerg Med 2023; 2023:7301460. [PMID: 37457790 PMCID: PMC10344630 DOI: 10.1155/2023/7301460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 06/15/2023] [Accepted: 06/29/2023] [Indexed: 07/18/2023] Open
Abstract
Background The most frequent atrioventricular tachycardia in the emergency room is atrioventricular nodal reentrant tachycardia (AVNRT). The first treatment option for ending stable narrow QRS complex SVTs is vagal maneuvers and adenosine. When adenosine or vagal maneuvers fail to change a patient's rhythm to normal sinus rhythm, long-acting AV nodal-blocking medications, including nondihydropyridine calcium channel blockers (verapamil and diltiazem), flecainide, or beta-blockers, are employed. Electricity (synchronized cardioversion) is the preferred form of treatment for unstable patients. Case Presentation. A 40-year-old male patient presented to the Emergency Department of Dubti General Hospital, the Afar regional state in Ethiopia, with a complaint of shortness of breath, palpitation, extreme fatigue, and chest pain of a day's duration. His blood pressure was 80/50 mmHg, he had cold extremities and a weak radial pulse, and his apical heart rate was fast, making it difficult to count. His electrocardiogram (ECG) showed paroxysmal supraventricular tachycardia (PSVT) with a heart rate of 200. He was a candidate for electrical cardioversion due to unstable PSVT, but he and his family members refused to give consent. Even though he is not indicated for pharmacologic therapy, none of the commonly used drugs were available at the hospital. We managed him with digoxin, and the outcome was positive. Conclusion Even though we could not find a clear recommendation regarding the use of digoxin for patients with unstable PSVT (AVNRT), by taking into consideration its negative chronotropic effect and its action to suppress the AV nodal conduction velocity, it may reduce the heart rate, and it can be used as an alternative in such difficult scenarios and a resource-limited setting. But this should be further investigated.
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Affiliation(s)
- Belayneh Dessie Kassa
- Department of Emergency and Critical Care Medicine, Debre Tabor University, Debre Tabor, Ethiopia
| | - Mekbib Amede
- Department of Emergency and Critical Care Medicine, Debre Tabor University, Debre Tabor, Ethiopia
| | - Mollalign Wubante
- Department of Emergency and Critical Care Medicine, Debre Tabor University, Debre Tabor, Ethiopia
| | - Mebratu Libanos
- Department of Internal Medicine, Debre Tabor University, Debre Tabor, Ethiopia
| | - Kumlachew Geta
- Department of Anesthesia, Debre Tabor University, Debre Tabor, Ethiopia
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4
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Purtell C, Enriquez AD. Should we burn our bridges with AVNRT ablation? JOURNAL OF INTERVENTIONAL CARDIAC ELECTROPHYSIOLOGY : AN INTERNATIONAL JOURNAL OF ARRHYTHMIAS AND PACING 2023:10.1007/s10840-023-01501-3. [PMID: 36787092 DOI: 10.1007/s10840-023-01501-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 01/30/2023] [Indexed: 02/15/2023]
Affiliation(s)
- Christopher Purtell
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, 06510, USA
| | - Alan D Enriquez
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, 06510, USA.
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O'Leary ET, Harris J, Gauvreau K, Gentry C, Dionne A, Abrams DJ, Alexander ME, Bezzerides VJ, DeWitt ES, Triedman JK, Walsh EP, Mah DY. Radiofrequency Catheter Ablation for Pediatric Atrioventricular Nodal Reentrant Tachycardia: Impact of Age on Procedural Methods and Durable Success. J Am Heart Assoc 2022; 11:e022799. [PMID: 35699163 PMCID: PMC9238659 DOI: 10.1161/jaha.121.022799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Catheter-based slow-pathway modification (SPM) is the treatment of choice for symptomatic atrioventricular nodal reentrant tachycardia (AVNRT). We sought to investigate the interactions between patient age and procedural outcomes in pediatric patients undergoing catheter-based SPM for AVNRT. Methods and Results A retrospective cohort study was performed, including consecutive patients undergoing acutely successful SPM for AVNRT from 2008 to 2017. Those with congenital heart disease, cardiomyopathy, and accessory pathways were excluded. Patients were stratified by age quartile at time of SPM. The primary outcome was AVNRT recurrence. A total of 512 patients underwent successful SPM for AVNRT. Age quartile 1 had 129 patients with a median age and weight of 8.9 years and 30.6 kg, respectively. Radiofrequency energy was used in 98% of cases. Follow-up was available in 447 (87%) patients with a median duration of 0.8 years (interquartile range, 0.2-2.5 years). AVNRT recurred in 22 patients. Multivariable Cox proportional hazard modeling identified atypical AVNRT (hazard ratio [HR], 5.83; 95% CI, 2.01-16.96; P=0.001), dual atrioventricular nodal only (HR, 4.09; 95% CI, 1.39-12.02; P=0.011), total radiofrequency lesions (HR, 1.06 per lesion; 95% CI, 1.01-1.12; P=0.032), and the use of a long sheath (HR, 3.52; 95% CI, 1.23-10.03; P=0.010) as predictors of AVNRT recurrence; quartile 1 patients were not at higher risk of recurrence (HR, 0.45; 95% CI, 0.10-1.97; P=0.29). Complete heart block requiring permanent pacing occurred in one quartile 2 patient at 14.9 years of age. Conclusions Pediatric AVNRT can be treated with radiofrequency-SPM with high procedural efficacy and minimal risk of complications, including heart block. Atypical AVNRT and dual atrioventricular nodal physiology without inducible tachycardia remain challenging substrates.
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Affiliation(s)
- Edward T O'Leary
- Department of Cardiology Boston Children's Hospital Boston MA.,Harvard Medical School Boston MA
| | - Jamie Harris
- Department of Cardiology Boston Children's Hospital Boston MA.,Harvard Medical School Boston MA
| | - Kimberlee Gauvreau
- Department of Cardiology Boston Children's Hospital Boston MA.,Harvard Medical School Boston MA
| | - Courtney Gentry
- Department of Cardiology Boston Children's Hospital Boston MA.,Harvard Medical School Boston MA
| | - Audrey Dionne
- Department of Cardiology Boston Children's Hospital Boston MA.,Harvard Medical School Boston MA
| | - Dominic J Abrams
- Department of Cardiology Boston Children's Hospital Boston MA.,Harvard Medical School Boston MA
| | - Mark E Alexander
- Department of Cardiology Boston Children's Hospital Boston MA.,Harvard Medical School Boston MA
| | - Vassilios J Bezzerides
- Department of Cardiology Boston Children's Hospital Boston MA.,Harvard Medical School Boston MA
| | - Elizabeth S DeWitt
- Department of Cardiology Boston Children's Hospital Boston MA.,Harvard Medical School Boston MA
| | - John K Triedman
- Department of Cardiology Boston Children's Hospital Boston MA.,Harvard Medical School Boston MA
| | - Edward P Walsh
- Department of Cardiology Boston Children's Hospital Boston MA.,Harvard Medical School Boston MA
| | - Douglas Y Mah
- Department of Cardiology Boston Children's Hospital Boston MA.,Harvard Medical School Boston MA
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6
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Qureshi K, Naeem N, Saleem S, Chaudhry MS, Pasha F. Recurrent Episodes of Paroxysmal Supraventricular Tachycardia Triggered by Dyspepsia: A Rare Case of Gastrocardiac Syndrome. Cureus 2021; 13:e17966. [PMID: 34667658 PMCID: PMC8516136 DOI: 10.7759/cureus.17966] [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] [Accepted: 09/14/2021] [Indexed: 11/05/2022] Open
Abstract
Supraventricular tachycardia (SVT) refers to the narrow complex tachycardia originating at or above the bundle of His. Several risk factors are associated with the development and recurrence of SVT, but its association with gastric problems, especially dyspepsia, is relatively rare. We report the case of a 54-year-old female who presented to the emergency room (ER) with palpitations, which were diagnosed as an episode of paroxysmal supraventricular tachycardia (PSVT). She had a history of PSVT in the past, along with hypertension and dyspepsia. After thorough history and examination, dyspepsia was identified as the common trigger of her PSVT episodes, pointing towards the likelihood of gastrocardiac symptoms. Therefore, an appropriate regimen of beta-blockers, proton pump inhibitors (PPIs), and anti-foaming agents (simethicone) was prescribed to manage her symptoms with the plan to perform a catheter ablation later.
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Affiliation(s)
- Khadija Qureshi
- Internal Medicine, Bucks County Kidney Specialists, Langhorne, USA
| | - Nauman Naeem
- Internal Medicine, Allama Iqbal Memorial Hospital, Sialkot, PAK
| | | | - Maida S Chaudhry
- Internal Medicine, DHR Health Institute for Research and Development, Edinburg, USA
| | - Fajar Pasha
- Internal Medicine, Rawalpindi Medical University, Rawalpindi, PAK.,Internal Medicine, Holy Family Hospital, Rawalpindi, PAK
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7
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Ahmad F, Abu Sneineh M, Patel RS, Rohit Reddy S, Llukmani A, Hashim A, Haddad DR, Gordon DK. In The Line of Treatment: A Systematic Review of Paroxysmal Supraventricular Tachycardia. Cureus 2021; 13:e15502. [PMID: 34268033 PMCID: PMC8261787 DOI: 10.7759/cureus.15502] [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: 02/26/2021] [Accepted: 06/07/2021] [Indexed: 11/19/2022] Open
Abstract
Paroxysmal supraventricular tachycardia (PSVT) is a common tachyarrhythmia, and an electrocardiogram is the best tool for making a diagnosis. If Valsalva maneuvers and carotid sinus massage do not give positive results, then the next choice is either adenosine or calcium channel blockers. At this time, adenosine is the drug of choice of treatment. Verapamil and diltiazem are the most commonly used calcium channel blockers (CCBs). This review aimed to compare the efficacy of both drugs in the treatment of PSVT. We utilized the databases PubMed Central and Medline by using keywords: "calcium channel blockers OR adenosine AND supraventricular tachycardia." In the end, we finalized 32 studies, including observational studies, literature reviews, systematic reviews/metanalysis, and randomized control trials. We included articles only in the English language and related to humans. Two authors completed the quality assessment and evaluation of bias according to specific guidelines. Only high-quality studies were included in this systematic review based on the cut-off score of seven or above. Calcium channel blockers have a longer half-life than adenosine and were previously used as the drug of choice in the treatment of PSVT. Calcium channel blockers are safe if given slowly; however, adenosine is safer and useful when an electrocardiogram is uncertain. We compared both drugs in certain aspects and found equal efficacy. Though safer, adenosine was found to have a higher cost and a higher probability of re-initiation arrhythmia compared to calcium channel blockers.
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Affiliation(s)
- Farrukh Ahmad
- Emergency Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA.,Emergency Medicine, Beaumont Hospital, Dublin, IRL
| | - Majdi Abu Sneineh
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Ravi S Patel
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Sai Rohit Reddy
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Adiona Llukmani
- Medical Education and Simulation, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Ayat Hashim
- Internal Medicine/Pediatrics, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Dana R Haddad
- Plastic and Reconstructive Surgery, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Domonick K Gordon
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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8
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Abstract
Supraventricular tachycardia (SVT) is a common cause of hospital admissions and can cause significant patient discomfort and distress. The most common SVTs include atrioventricular nodal re-entrant tachycardia, atrioventricular re-entrant tachycardia and atrial tachycardia. In many cases, the underlying mechanism can be deduced from electrocardiography during tachycardia, comparing it with sinus rhythm, and assessing the onset and offset of tachycardia. Recent European Society of Cardiology guidelines continue to advocate the use of vagal manoeuvres and adenosine as first-line therapies in the acute diagnosis and management of SVT. Alternative therapies include the use of beta-blockers and calcium channel blockers. All patients treated for SVT should be referred for a heart rhythm specialist opinion. Long-term treatment is dependent on several factors including frequency of symptoms, risk stratification, and patient preference. Management can range from conservative, if symptoms are rare and the patient is low risk, to catheter ablation which is curative in the majority of patients.
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Affiliation(s)
- Irum D Kotadia
- King's College London, London, UK and Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Steven E Williams
- King's College London, London, UK and Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Mark O'Neill
- King's College London, London, UK and Guy's and St Thomas' NHS Foundation Trust, London, UK
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9
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Next-generation sequencing of AV nodal reentrant tachycardia patients identifies broad spectrum of variants in ion channel genes. Eur J Hum Genet 2018; 26:660-668. [PMID: 29396561 DOI: 10.1038/s41431-017-0092-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 12/01/2017] [Accepted: 12/05/2017] [Indexed: 12/19/2022] Open
Abstract
Atrioventricular nodal reentry tachycardia (AVNRT) is the most common form of regular paroxysmal supraventricular tachycardia. This arrhythmia affects women twice as frequently as men, and is often diagnosed in patients <40 years of age. Familial clustering, early onset of symptoms and lack of structural anomaly indicate involvement of genetic factors in AVNRT pathophysiology. We hypothesized that AVNRT patients have a high prevalence of variants in genes that are highly expressed in the atrioventricular conduction axis of the heart and potentially involved in arrhythmic diseases. Next-generation sequencing of 67 genes was applied to the DNA profile of 298 AVNRT patients and 10 AVNRT family members using HaloPlex Target Enrichment System. In total, we identified 229 variants in 60 genes; 215 missenses, four frame shifts, four codon deletions, three missense and splice sites, two stop-gain variants, and one start-lost variant. Sixty-five of these were not present in the Exome Aggregation Consortium (ExAC) database. Furthermore, we report two AVNRT families with co-segregating variants. Seventy-five of 284 AVNRT patients (26.4%) and three family members to different AVNRT probands had one or more variants in genes affecting the sodium handling. Fifty-four out of 284 AVNRT patients (19.0%) had variants in genes affecting the calcium handling of the heart. We furthermore find a large proportion of variants in the HCN1-4 genes. We did not detect a significant enrichment of rare variants in the tested genes. This could be an indication that AVNRT might be an electrical arrhythmic disease with abnormal sodium and calcium handling.
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10
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Fragakis N, Krexi L, Kyriakou P, Sotiriadou M, Lazaridis C, Karamanolis A, Dalampyras P, Tsakiroglou S, Skeberis V, Tsalikakis D, Vassilikos V. Electrophysiological markers predicting impeding AV-block during ablation of atrioventricular nodal reentry tachycardia. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2017; 41:7-13. [DOI: 10.1111/pace.13245] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 11/08/2017] [Accepted: 11/09/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Nikolaos Fragakis
- Third Department of Cardiology; Hippokration Hospital; Medical School; Aristotle University of Thessaloniki; Thessaloniki Greece
| | - Lydia Krexi
- Third Department of Cardiology; Hippokration Hospital; Medical School; Aristotle University of Thessaloniki; Thessaloniki Greece
| | - Panagiota Kyriakou
- Third Department of Cardiology; Hippokration Hospital; Medical School; Aristotle University of Thessaloniki; Thessaloniki Greece
| | - Melani Sotiriadou
- Third Department of Cardiology; Hippokration Hospital; Medical School; Aristotle University of Thessaloniki; Thessaloniki Greece
| | - Charalambos Lazaridis
- Third Department of Cardiology; Hippokration Hospital; Medical School; Aristotle University of Thessaloniki; Thessaloniki Greece
| | - Athanasios Karamanolis
- Third Department of Cardiology; Hippokration Hospital; Medical School; Aristotle University of Thessaloniki; Thessaloniki Greece
| | - Panagiotis Dalampyras
- Third Department of Cardiology; Hippokration Hospital; Medical School; Aristotle University of Thessaloniki; Thessaloniki Greece
| | - Stelios Tsakiroglou
- Third Department of Cardiology; Hippokration Hospital; Medical School; Aristotle University of Thessaloniki; Thessaloniki Greece
| | - Vassilios Skeberis
- Third Department of Cardiology; Hippokration Hospital; Medical School; Aristotle University of Thessaloniki; Thessaloniki Greece
| | - Dimitrios Tsalikakis
- Department of Informatics and Telecommunications; University of Western Macedonia; Macedonia Greece
| | - Vassilios Vassilikos
- Third Department of Cardiology; Hippokration Hospital; Medical School; Aristotle University of Thessaloniki; Thessaloniki Greece
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11
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Familial atrioventricular nodal re-entrant tachycardia: A case seriers and a systematic review. Indian Pacing Electrophysiol J 2017; 17:176-179. [PMID: 29231821 PMCID: PMC5784606 DOI: 10.1016/j.ipej.2017.07.005] [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: 04/14/2017] [Revised: 06/07/2017] [Accepted: 07/08/2017] [Indexed: 11/23/2022] Open
Abstract
Multiple reports of familial clustering suggest that genetic factors may contribute in the pathogenesis of atrioventricular nodal re-entrant tachycardia (AVNRT). We report three cases of AVNRT in a father and his two sons along with a review of literature of other similar cases. Electrophysiological studies induced typical AVNRT, which was successfully eliminated by radiofrequency ablation in all of them. Of the 22 reported cases, 96% had typical (slow-fast) variant of AVNRT. The predominant pattern of inheritance appears to be autosomal dominant, though other patterns may exist. Further research is needed to understand the genetic influence of AVNRT and its pathophysiology.
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12
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Abstract
The atrioventricular junction has a central role in electrophysiology, responsible for reentrant and automatic forms of supraventricular tachycardia. During atrioventricular nodal reentry tachycardia, the circuit involves 2 electrophysiologically separate pathways located in the vicinity of the atrioventricular node. Atrioventricular reentry tachycardia is caused by the presence of an accessory pathway located almost anywhere along the atrioventricular groove; the macroreentrant circuit involves the atrioventricular node, the accessory pathway and necessarily portions of atria and ventricles. Junctional tachycardia is a rare form of nonparoxysmal supraventricular tachycardia, secondary to enhanced automaticity or triggered activity. By analyzing a 12-lead electrocardiogram during sinus rhythm and tachycardia, it is possible to accurately diagnose the specific type of supraventricular tachycardia.
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13
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Ghani A, Ahsan I, Gottleib C. Hemochromatosis as Junctional Tachycardia, a Rare Presentation. Clin Pract 2017; 7:979. [PMID: 28839528 PMCID: PMC5543826 DOI: 10.4081/cp.2017.979] [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: 05/11/2017] [Accepted: 07/19/2017] [Indexed: 12/05/2022] Open
Abstract
We present here a 45-year-old male with no past medical problem who presented with palpitations. He was found to have supraventricular tachycardia intractable to medical therapy. Later his rhythm converted to junctional tachycardia. Further workup revealed hemochromatosis to be primary etiology causing the arrhythmia. The low index of suspicion for additional workup is key to diagnosis and successful outcome.
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14
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Katritsis DG, Josephson ME. Differential diagnosis of regular, narrow-QRS tachycardias. Heart Rhythm 2015; 12:1667-76. [DOI: 10.1016/j.hrthm.2015.03.046] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Indexed: 10/23/2022]
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15
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Jauregui-Abularach ME, Bazan V, Martí-Almor J, Cian D, Vallès E, Benito B, Meroño O, Bruguera-Cortada J. Caracterización de la vía lenta nodular en pacientes con taquicardia por reentrada nodular: implicaciones clínicas para guiar la ablación. Rev Esp Cardiol 2015. [DOI: 10.1016/j.recesp.2014.04.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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16
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Jauregui-Abularach ME, Bazan V, Martí-Almor J, Cian D, Vallès E, Benito B, Meroño O, Bruguera-Cortada J. Characterization of the nodal slow pathway in patients with nodal reentrant tachycardia: clinical implications for guiding ablation. ACTA ACUST UNITED AC 2014; 68:298-304. [PMID: 25440045 DOI: 10.1016/j.rec.2014.04.017] [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: 10/27/2013] [Accepted: 04/04/2014] [Indexed: 11/15/2022]
Abstract
INTRODUCTION AND OBJECTIVES Nodal slow pathway ablation is the treatment of choice for nodal reentrant tachycardia. No demographic, anatomic, or electrophysiologic variables have been reported to predict an exact location of the slow pathway in the atrioventricular node or its proximity to the fast pathway. The purpose of this study was to analyze these variables. METHODS The study prospectively included 54 patients (17 men; mean age, 55 [16] years) who had undergone successful slow pathway ablation. The refractory periods of both pathways and their differential conduction time were measured, and calculations were performed to obtain the distance from the His-bundle region (location of the fast pathway) to the coronary sinus ostium (to estimate the anteroposterior length of the triangle of Koch) and to the slow pathway area. RESULTS The differential conduction time (139 [98] ms) did not correlate with the His-coronary sinus distance (19 [6] mm; P=.6) or the His-slow pathway distance (14 [4] mm; P=.4). When the His-coronary sinus distance was larger, the His-slow pathway distance was also larger (r=0.652; P<.01) and the anatomic correlation between the triangle dimensions and the separation between the two pathways was confirmed. In patients older than 70 years, smaller triangle sizes and a shorter distance between both pathways were observed (P<.001). CONCLUSIONS A greater anteroposterior dimension of the triangle of Koch is associated with a slow-pathway location farther from the fast pathway. In elderly patients the two pathways are closer together (higher risk of atrioventricular block).
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Affiliation(s)
| | - Victor Bazan
- Unidad de Arritmias, Servicio de Cardiología, Hospital del Mar, Barcelona, Spain
| | - Julio Martí-Almor
- Unidad de Arritmias, Servicio de Cardiología, Hospital del Mar, Barcelona, Spain
| | - Debora Cian
- Unidad de Arritmias, Servicio de Cardiología, Hospital del Mar, Barcelona, Spain
| | - Ermengol Vallès
- Unidad de Arritmias, Servicio de Cardiología, Hospital del Mar, Barcelona, Spain
| | - Begoña Benito
- Unidad de Arritmias, Servicio de Cardiología, Hospital del Mar, Barcelona, Spain
| | - Oona Meroño
- Unidad de Arritmias, Servicio de Cardiología, Hospital del Mar, Barcelona, Spain
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Kirmanoglou K, Peiker C, Clasen L, Shin DI, Kelm M, Meyer C. [Dual AV nodal nonreentry tachycardia (DAVNNT): unrecognized differential diagnosis with far-reaching consequences]. Herzschrittmacherther Elektrophysiol 2014; 25:109-115. [PMID: 24830917 DOI: 10.1007/s00399-014-0310-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 03/26/2014] [Indexed: 06/03/2023]
Abstract
BACKGROUND The dual atrioventricular nodal nonreentry tachycardia (DAVNNT) is a rare form of tachycardia which occurs due to a time delayed double antegrade conduction via the slow and fast atrioventricular nodal pathways. Its epidemiology is not known so far. The aim of this article is to present the clinical findings in a series of patients with DAVNNT. MATERIALS AND METHODS We retrospectively analyzed our database of patients who successfully underwent radiofrequency catheter ablation between January 2012 and March 2013 due to diagnosed supraventricular tachycardia. RESULTS In 3 out of 231 patients DAVNNT could be successfully treated by slow pathway modulation/ablation. Patients presented with widely varying symptoms including syncope, palpitations which had been mistaken as atrial fibrillation, and inappropriate defibrillator shocks due to suspected ventricular tachycardia. CONCLUSIONS The DAVNNT seems to be more common than previously thought. This important differential diagnosis needs to be taken into consideration as slow pathway modulation can be curative while a misdiagnosis, such as atrial fibrillation or ventricular tachycardia might result in over-treatment in patients with this arrhythmia.
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Affiliation(s)
- Kiriakos Kirmanoglou
- Abteilung für Rhythmologie, Klinik für Kardiologie Pneumologie und Angiologie, Heinrich-Heine Universität Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Deutschland
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18
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Al Mehairi M, Al Ghamdi SA, Dagriri K, Al Fagih A. Simultaneous antegrade dual AV node conduction initiates AV nodal re-entrant tachycardia (a rare initiation mechanism). J Saudi Heart Assoc 2013; 25:35-7. [PMID: 24174843 DOI: 10.1016/j.jsha.2012.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2012] [Revised: 07/04/2012] [Accepted: 07/22/2012] [Indexed: 10/28/2022] Open
Abstract
Typical atrioventricular nodal reentrant tachycardia (AVNRT) is the most common paroxysmal supraventricular tachycardia among adults. The concept of dual pathway physiology remains widely accepted, although this physiology likely results from the functional properties of anisotropic tissue within the triangle of Koch, rather than anatomically distinct tracts of conduction. AVNRT is typically induced with anterograde block over the fast pathway and conduction over the slow pathway, with subsequent retrograde conduction over the fast pathway. On rare occasions, anterograde AV node conduction occurs simultaneously through fast and slow pathways resulting in two ventricular beats in response to one atrial beat. We report a case of AVNRT where the tachycardia is always induced by the same mechanism described above. Successful ablation was achieved by slow pathway modification.
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Affiliation(s)
- M Al Mehairi
- Department of Adult Cardiology, Prince Sultan Cardiac Center, Riyadh
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19
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Crosato M, Vaccari D, Calzolari V, Neri G, Olivari Z, Mantovan R. Catheter ablation of atrioventricular nodal reentrant tachycardia in patients with a prolonged PR interval at sinus rhythm. J Cardiovasc Med (Hagerstown) 2012; 13:325-9. [PMID: 22343259 DOI: 10.2459/jcm.0b013e3283511f75] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Radiofrequency transcatheter ablation is an effective and safe treatment for atrioventricular node reentry tachycardia. Slow pathway ablation is considered the ablative technique of choice, but when atrioventricular nodal reentrant tachycardia is associated with a prolonged PR interval at sinus rhythm, a higher risk of delayed atrioventricular (AV) block has been reported. Studies on the subject are few, enrolling low numbers of patients with variable selection criteria and producing different results. Hence, optimal ablation strategy remains controversial. The aim of this study is to review the available knowledge on the topic. Experience from our centers is also briefly reported.
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Affiliation(s)
- Martino Crosato
- Cardiovascular Department, Treviso Hospital 'Ca' Foncello', Treviso, Italy
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20
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Ardashev AV, Makarenko AS, Zhelyakov EG, Shavarov AA. Atrioventricular nodal reentrant tachycardia treatment using novel potential. Asian Cardiovasc Thorac Ann 2010; 18:529-35. [PMID: 21149400 DOI: 10.1177/0218492310387852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Radiofrequency ablation of atrioventricular nodal reentrant tachycardia is commonly guided by slow and sharp bipolar potentials of the atrioventricular slow nodal pathway. We optimized the morphology of the guiding potential by unipolar mapping of the slow nodal pathway. We identified a novel unipolar dual-component atrial electrogram at the anterior limb of the coronary sinus ostium. The first component was a positive delta-wave type that corresponded to the isoelectric phase on a bipolar electrogram. The second component had fast biphasic morphology and corresponded to the R wave on a bipolar atrial electrogram. Of 104 consecutive patients with typical atrioventricular nodal reentrant tachycardia, 51 were treated with ablation guided by the novel potential, and 53 underwent ablation using the conventional technique. There was no recurrence of tachycardia in any of these patients. In those treated by the novel potential, there was significantly less radiofrequency power applied and a shorter duration of application than in patients treated by the traditional approach. The novel approach to mapping and ablation of the slow nodal pathway in atrioventricular nodal reentrant tachycardia guided by unipolar recording was safe and effective, and comparable to the traditional technique.
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Affiliation(s)
- Andrey V Ardashev
- Clinical Hospital of Federal Biomedical Agency of Russia, Moscow, Russia.
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21
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CORRADI DOMENICO, MAESTRI ROBERTA, MACCHI EMILIO, CALLEGARI SERGIO. Clinical Reviews: The Atria: From Morphology to Function. J Cardiovasc Electrophysiol 2010; 22:223-35. [DOI: 10.1111/j.1540-8167.2010.01887.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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22
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23
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KHAN AAMIRH, KHADEM ALIASGHAR, BASTA MAGDYN, GARDNER MARTINJ, PARKASH RATIKA, GULA LORNEJ, SAPP JOHNL. Differential Entrainment Distinguishes Atrioventricular Nodal Reentry Tachycardia from Atrioventricular Reentrant Tachycardia. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2010; 33:1335-41. [DOI: 10.1111/j.1540-8159.2010.02833.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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24
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Combes S, Hausman P, Albenque JP, Combes N. A "regular irregular" tachycardia: what is the mechanism? J Cardiovasc Electrophysiol 2010; 21:719-20. [PMID: 20132403 DOI: 10.1111/j.1540-8167.2010.01719.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Stéphane Combes
- Electrophysiology and Pacing/Defibrillation Department, Clinique Pasteur, Toulouse, France.
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25
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Katritsis DG. Left septal slow pathway ablation for atrioventricular nodal reentrant tachycardia. Europace 2010; 12:1042-3. [DOI: 10.1093/europace/euq113] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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26
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Bortone A, Boveda S, Jandaud S, Combes N, Donzeau JP, Marijon E, Albenque JP. Gradual power titration using radiofrequency energy: a safe method for slow-pathway ablation in the setting of atrioventricular nodal re-entrant tachycardia. Europace 2008; 11:178-83. [DOI: 10.1093/europace/eun333] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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27
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Fujiki A, Sakamoto T, Sakabe M, Tsuneda T, Sugao M, Nakatani Y, Mizumaki K, Inoue H. Junctional rhythm associated with ventriculoatrial block during slow pathway ablation in atypical atrioventricular nodal re-entrant tachycardia. Europace 2008; 10:982-7. [DOI: 10.1093/europace/eun151] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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28
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DUCCESCHI VALENTINO, OTTAVIANO LUCA, SANTORO MICHELE, CITRO RODOLFO, VITALE RAFFAELE, GREGORIO GIOVANNI. Intrahisian Conduction Disease and Junctional Ectopic Tachycardia. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2008; 31:378-81. [DOI: 10.1111/j.1540-8159.2008.01001.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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FREEDBERG NAHUMA. Learning While Burning Revisited. J Cardiovasc Electrophysiol 2007; 19:7-9. [DOI: 10.1111/j.1540-8167.2007.00992.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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30
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Katritsis DG, Becker A. The atrioventricular nodal reentrant tachycardia circuit: A proposal. Heart Rhythm 2007; 4:1354-60. [PMID: 17905343 DOI: 10.1016/j.hrthm.2007.05.026] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2007] [Accepted: 05/24/2007] [Indexed: 11/17/2022]
Abstract
Several models of the atrioventricular nodal reentrant tachycardia circuit have been proposed. Recently, there has been experimental and clinical electrophysiology evidence that the right and left inferior extensions of the human atriventricular node and the atrionodal inputs they facilitate may provide the anatomic substrate of the slow pathway. Inferior nodal extensions appear to constitute a necessary limb of the tachycardia circuit in all forms of atrioventricular nodal reentrant tachycardia and represent the ablation target for all forms of this arrhythmia. Anatomic variations of multiple atrionodal inputs via atrial transitional cells may create the conditions for tachycardia inducibility and differing patterns of retrograde atrial activation. In the present article, we summarize the available evidence and propose a comprehensive model of the tachycardia circuit for all forms of atrioventricular nodal reentrant tachycardia based on the concept of atrionodal inputs.
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Katritsis DG, Ellenbogen KA, Becker AE, Camm AJ. Retrograde slow pathway conduction in patients with atrioventricular nodal re-entrant tachycardia. ACTA ACUST UNITED AC 2007; 9:458-65. [PMID: 17478461 DOI: 10.1093/europace/eum067] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
AIMS To study retrograde slow pathway conduction by means of right- and left-sided septal mapping. METHODS AND RESULTS Nineteen patients with slow-fast atrioventricular nodal re-entrant tachycardia (AVNRT) were studied before and after slow pathway ablation. Simultaneous His bundle recordings from right and left sides of the septum, using trans-aortic and trans-septal electrodes, were made during right ventricular pacing. Pre-ablation, decremental retrograde ventriculo-atrial (VA) conduction without jumps or discontinuities was recorded in eight patients (group 1). In six patients, retrograde conduction jumps were demonstrated (group 2) and in the remaining four patients, there was minimal prolongation of stimulus to atrium (St-A) intervals (group 3). The maximal difference (Delta St-A) between St-A intervals obtained with pacing at a constant cycle length of 500 ms and at the cycle length with maximal retrograde VA prolongation was significantly longer measured from the right His compared with the left His (122 +/- 25 vs. 110 +/- 33 ms, P = 0.02, respectively) in group 1 and group 2 (140 +/- 23 vs. 110 +/- 35 ms, P = 0.03), but not in group 3 (10 +/- 4 vs. 13 +/- 8 ms, P = 0.35). Post-ablation, Delta St-A intervals were similar between right and left His recordings (77 +/- 37 vs. 76 +/- 33 ms, P = 0.53, respectively) in group 1, (100 +/- 24 vs. 103 +/- 21 ms, P = 0.35) group 2, and (63 +/- 32 vs. 66 +/- 33 ms, P = 0.35) group 3. CONCLUSION In patients with typical AVNRT, retrograde conduction through the slow pathway results in earliest retrograde atrial activation on the left side of the septum and catheter ablation in the right inferoparaseptal area abolishes this pattern. These findings are compatible with the concept of slow pathway conduction by means of the inferior AV nodal extensions.
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32
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Katritsis DG, Ellenbogen KA, Becker AE. Atrial activation during atrioventricular nodal reentrant tachycardia: Studies on retrograde fast pathway conduction. Heart Rhythm 2006; 3:993-1000. [PMID: 16945788 DOI: 10.1016/j.hrthm.2006.05.029] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2006] [Accepted: 05/30/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND Detailed right and left septal mapping of retrograde atrial activation during typical atrioventricular nodal reentrant tachycardia (AVNRT) has not been undertaken and may provide insight into the complex physiology of AVNRT, especially the anatomic localization of the fast and slow pathways. OBJECTIVES The purpose of this study was to investigate the pattern of retrograde atrial activation during typical AVNRT by means of right-sided and left-sided septal mapping and implementation of pacing maneuvers for separating atrial and ventricular electrograms recorded during tachycardia. METHODS Twenty-two patients with slow-fast AVNRT were studied by means of simultaneous His-bundle recordings from the right and left sides of the septum. Patterns of retrograde atrial activation were recorded during tachycardia following specific pacing maneuvers and during right ventricular apical (RVA) pacing at the tachycardia cycle length. RESULTS The pattern of retrograde atrial activation could be mapped in 17 of 22 patients during AVNRT. In 9 (53%) patients, the earliest retrograde atrial activation was recorded on the left side of the septum, in 3 (17%) patients on the right side, and in 5 (29%) patients both right and left atrial septal electrograms occurred simultaneously. Stimulus to atrial electrogram times recorded during RVA pacing in 14 patients were 138.5 ms from the right His bundle, 134.5 ms from the left His bundle, and 148.0 ms from the ostium of the coronary sinus (P <.001). The predominant site of earliest retrograde atrial activation during RVA pacing was the left side of the septum (10 patients [71%]). Only 8 (57%) of 14 patients demonstrated concordance in the pattern of retrograde atrial activation during AVNRT and RVA pacing. CONCLUSION Earliest retrograde atrial activation during AVNRT is most often recorded on the left side of the septum. Breakthrough of atrial activation may be discordant from that observed during RVA pacing.
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