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Takase B, Ikeda T, Shimizu W, Abe H, Aiba T, Chinushi M, Koba S, Kusano K, Niwano S, Takahashi N, Takatsuki S, Tanno K, Watanabe E, Yoshioka K, Amino M, Fujino T, Iwasaki YK, Kohno R, Kinoshita T, Kurita Y, Masaki N, Murata H, Shinohara T, Yada H, Yodogawa K, Kimura T, Kurita T, Nogami A, Sumitomo N. JCS/JHRS 2022 Guideline on Diagnosis and Risk Assessment of Arrhythmia. Circ J 2024; 88:1509-1595. [PMID: 37690816 DOI: 10.1253/circj.cj-22-0827] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Affiliation(s)
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School
| | - Haruhiko Abe
- Department of Heart Rhythm Management, University of Occupational and Environmental Health, Japan
| | - Takeshi Aiba
- Department of Clinical Laboratory Medicine and Genetics, National Cerebral and Cardiovascular Center
| | - Masaomi Chinushi
- School of Health Sciences, Niigata University School of Medicine
| | - Shinji Koba
- Division of Cardiology, Department of Medicine, Showa University School of Medicine
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Shinichi Niwano
- Department of Cardiovascular Medicine, Kitasato University School of Medicine
| | - Naohiko Takahashi
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Seiji Takatsuki
- Department of Cardiology, Keio University School of Medicine
| | - Kaoru Tanno
- Cardiology Division, Cardiovascular Center, Showa University Koto-Toyosu Hospital
| | - Eiichi Watanabe
- Division of Cardiology, Department of Internal Medicine, Fujita Health University Bantane Hospital
| | | | - Mari Amino
- Department of Cardiology, Tokai University School of Medicine
| | - Tadashi Fujino
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine
| | - Yu-Ki Iwasaki
- Department of Cardiovascular Medicine, Nippon Medical School
| | - Ritsuko Kohno
- Department of Heart Rhythm Management, University of Occupational and Environmental Health, Japan
| | - Toshio Kinoshita
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine
| | - Yasuo Kurita
- Cardiovascular Center, International University of Health and Welfare, Mita Hospital
| | - Nobuyuki Masaki
- Department of Intensive Care Medicine, National Defense Medical College
| | | | - Tetsuji Shinohara
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Hirotaka Yada
- Department of Cardiology, International University of Health and Welfare, Mita Hospital
| | - Kenji Yodogawa
- Department of Cardiovascular Medicine, Nippon Medical School
| | - Takeshi Kimura
- Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | | | - Akihiko Nogami
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | - Naokata Sumitomo
- Department of Pediatric Cardiology, Saitama Medical University International Medical Center
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Takase B, Ikeda T, Shimizu W, Abe H, Aiba T, Chinushi M, Koba S, Kusano K, Niwano S, Takahashi N, Takatsuki S, Tanno K, Watanabe E, Yoshioka K, Amino M, Fujino T, Iwasaki Y, Kohno R, Kinoshita T, Kurita Y, Masaki N, Murata H, Shinohara T, Yada H, Yodogawa K, Kimura T, Kurita T, Nogami A, Sumitomo N. JCS/JHRS 2022 Guideline on Diagnosis and Risk Assessment of Arrhythmia. J Arrhythm 2024; 40:655-752. [PMID: 39139890 PMCID: PMC11317726 DOI: 10.1002/joa3.13052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Accepted: 04/22/2024] [Indexed: 08/15/2024] Open
Affiliation(s)
| | - Takanori Ikeda
- Department of Cardiovascular MedicineToho University Faculty of Medicine
| | - Wataru Shimizu
- Department of Cardiovascular MedicineNippon Medical School
| | - Haruhiko Abe
- Department of Heart Rhythm ManagementUniversity of Occupational and Environmental HealthJapan
| | - Takeshi Aiba
- Department of Clinical Laboratory Medicine and GeneticsNational Cerebral and Cardiovascular Center
| | | | - Shinji Koba
- Division of Cardiology, Department of MedicineShowa University School of Medicine
| | - Kengo Kusano
- Department of Cardiovascular MedicineNational Cerebral and Cardiovascular Center
| | - Shinichi Niwano
- Department of Cardiovascular MedicineKitasato University School of Medicine
| | - Naohiko Takahashi
- Department of Cardiology and Clinical Examination, Faculty of MedicineOita University
| | | | - Kaoru Tanno
- Cardiovascular Center, Cardiology DivisionShowa University Koto‐Toyosu Hospital
| | - Eiichi Watanabe
- Division of Cardiology, Department of Internal MedicineFujita Health University Bantane Hospital
| | | | - Mari Amino
- Department of CardiologyTokai University School of Medicine
| | - Tadashi Fujino
- Department of Cardiovascular MedicineToho University Faculty of Medicine
| | - Yu‐ki Iwasaki
- Department of Cardiovascular MedicineNippon Medical School
| | - Ritsuko Kohno
- Department of Heart Rhythm ManagementUniversity of Occupational and Environmental HealthJapan
| | - Toshio Kinoshita
- Department of Cardiovascular MedicineToho University Faculty of Medicine
| | - Yasuo Kurita
- Cardiovascular Center, Mita HospitalInternational University of Health and Welfare
| | - Nobuyuki Masaki
- Department of Intensive Care MedicineNational Defense Medical College
| | | | - Tetsuji Shinohara
- Department of Cardiology and Clinical Examination, Faculty of MedicineOita University
| | - Hirotaka Yada
- Department of CardiologyInternational University of Health and Welfare Mita Hospital
| | - Kenji Yodogawa
- Department of Cardiovascular MedicineNippon Medical School
| | - Takeshi Kimura
- Cardiovascular MedicineKyoto University Graduate School of Medicine
| | | | - Akihiko Nogami
- Department of Cardiology, Faculty of MedicineUniversity of Tsukuba
| | - Naokata Sumitomo
- Department of Pediatric CardiologySaitama Medical University International Medical Center
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Hirata S, Nagashima K, Kaneko Y, Tamura S, Mori H, Nishiuchi S, Tokuda M, Kawaji T, Hayashi T, Nishimura T, Fukunaga M, Kishihara J, Fukaya H, Teranishi J, Takami M, Okada M, Miyazaki N, Watanabe R, Wakamatsu Y, Okumura Y. Recurrent episodes of atrioventricular nodal reentrant tachycardia: Sites of ablation success, ablation endpoint, and primary culprits for recurrence. J Arrhythm 2024; 40:552-559. [PMID: 38939776 PMCID: PMC11199834 DOI: 10.1002/joa3.13060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 03/12/2024] [Accepted: 05/02/2024] [Indexed: 06/29/2024] Open
Abstract
Background Atrioventricular nodal reentrant tachycardia (AVNRT) sometimes recurs even after anatomical slow pathway (SP) ablation targeting the rightward inferior extension (RIE). This multicenter study aimed to determine the reasons for AVNRT recurrence. Methods and Results Forty-six patients were treated successfully for recurrent AVNRT. Initial treatment was for 38 slow-fast AVNRTs, 3 fast-slow AVNRTs, 2 slow-slow AVNRTs, 2 slow-fast and fast-slow AVNRTs, and 1 noninducible AVNRT. All initial treatments were of RF application to the RIE; SP elimination was achieved in 11, dual AVN physiology was seen in 29, and AVNRT remained inducible in 5. The recurrent AVNRTs included 34 slow-fast AVNRTs, 6 fast-slow AVNRTs, 3 slow-slow AVNRTs, 2 slow-fast and fast-slow AVNRTs, and 1 slow-fast and slow-slow AVNRTs. Successful ablation site was within the RIE in 39 and left inferior extension in 7. In 30 of 39, the successful RIE site was in the same area or higher than that of the initial procedure. Conclusion For a high majority (around 85%) of patients in whom AVNRT recurs after initial ablation success, the site of a second successful procedure will be within the RIE even though the RIE was originally targeted. Furthermore, a high majority (around 86%) of sites of successful ablation will be higher than those originally targeted.
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Affiliation(s)
- Shu Hirata
- Division of Cardiology, Department of MedicineNihon University School of MedicineTokyoJapan
| | - Koichi Nagashima
- Division of Cardiology, Department of MedicineNihon University School of MedicineTokyoJapan
| | - Yoshiaki Kaneko
- Department of Cardiovascular MedicineGunma University Graduate School of MedicineMaebashiJapan
| | - Shuntaro Tamura
- Department of Cardiovascular MedicineGunma University Graduate School of MedicineMaebashiJapan
| | - Hitoshi Mori
- Department of CardiologySaitama Medical University International Medical CenterHidakaJapan
| | | | - Michifumi Tokuda
- Department of CardiologyThe Jikei University School of MedicineTokyoJapan
| | - Tetsuma Kawaji
- Department of CardiologyMitsubishi Kyoto HospitalKyotoJapan
| | - Tatsuya Hayashi
- Division of Cardiovascular Medicine, Saitama Medical CenterJichi Medical UniversityShimotsukeJapan
| | - Takuro Nishimura
- Department of Cardiovascular MedicineTokyo Medical and Dental UniversityTokyoJapan
| | - Masato Fukunaga
- Department of CardiologyKokura Memorial HospitalKitakyushuJapan
| | - Jun Kishihara
- Department of Cardiovascular MedicineKitasato University School of MedicineSagamiharaJapan
| | - Hidehira Fukaya
- Department of Cardiovascular MedicineKitasato University School of MedicineSagamiharaJapan
| | - Jin Teranishi
- Department of Cardiovascular MedicineJapanese Red Cross Society Himeji HospitalHimejiJapan
| | - Mitsuru Takami
- Division of Cardiovascular MedicineKobe University Graduate School of MedicineKobeJapan
| | - Masato Okada
- Cardiovascular CenterSakurabashi Watanabe HospitalOsakaJapan
| | - Naoko Miyazaki
- Cardiovascular CenterSakurabashi Watanabe HospitalOsakaJapan
| | - Ryuta Watanabe
- Division of Cardiology, Department of MedicineNihon University School of MedicineTokyoJapan
| | - Yuji Wakamatsu
- Division of Cardiology, Department of MedicineNihon University School of MedicineTokyoJapan
| | - Yasuo Okumura
- Division of Cardiology, Department of MedicineNihon University School of MedicineTokyoJapan
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Hirata S, Nagashima K, Watanabe R, Wakamatsu Y, Okumura Y. Pseudo-slow-fast atrioventricular nodal reentrant tachycardia: Is the fast pathway a criminal or innocent bystander? J Arrhythm 2024; 40:143-145. [PMID: 38333396 PMCID: PMC10848596 DOI: 10.1002/joa3.12955] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 10/22/2023] [Accepted: 10/30/2023] [Indexed: 02/10/2024] Open
Abstract
The intracardiac electrograms are shown during scanned single premature ventricular extrastimuli with a decreasing coupling interval in a very short RP tachycardia. What is the diagnosis and is the fast pathway essential for sustaining the tachycardia?
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Affiliation(s)
- Shu Hirata
- Division of Cardiology, Department of MedicineNihon University School of MedicineTokyoJapan
| | - Koichi Nagashima
- Division of Cardiology, Department of MedicineNihon University School of MedicineTokyoJapan
| | - Ryuta Watanabe
- Division of Cardiology, Department of MedicineNihon University School of MedicineTokyoJapan
| | - Yuji Wakamatsu
- Division of Cardiology, Department of MedicineNihon University School of MedicineTokyoJapan
| | - Yasuo Okumura
- Division of Cardiology, Department of MedicineNihon University School of MedicineTokyoJapan
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Nagashima K, Maruyama M, Kaneko Y, Sakai S, Sekihara T, Kawaji T, Iwakawa H, Egami Y, Ota C, Nagase S, Yagi T, Suzuki K, Fukaya H, Nakamura H, Mori H, Ueda A, Soejima K, Watanabe R, Wakamatsu Y, Hirata S, Hirata M, Okumura Y. Systematic observation-based diagnosis of atrioventricular nodal reentrant tachycardia with a bystander concealed nodoventricular pathway. J Arrhythm 2024; 40:131-142. [PMID: 38333409 PMCID: PMC10848616 DOI: 10.1002/joa3.12976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 11/20/2023] [Accepted: 12/05/2023] [Indexed: 02/10/2024] Open
Abstract
Background This study aimed to establish a systematic method for diagnosing atrioventricular nodal reentrant tachycardia (AVNRT) with a bystander concealed nodoventricular pathway (cNVP). Methods We analyzed 13 cases of AVNRT with a bystander cNVP, 11 connected to the slow pathway (cNVP-SP) and two to the fast pathway (cNVP-FP), along with two cases of cNVP-related orthodromic reciprocating tachycardia (ORT). Results The diagnostic process was summarized in three steps. Step 1 was identification of the presence of an accessory pathway by resetting the tachycardia with delay (n = 9) and termination without atrial capture (n = 4) immediately after delivery of a His-refractory premature ventricular contraction (PVC). Step 2 was exclusion of ORT by atrio-His block during the tachycardia (n = 4), disappearance of the reset phenomenon after the early PVC (n = 7), or dissociation of His from the tachycardia during ventricular overdrive pacing (n = 1). Moreover, tachycardia reset/termination without the atrial capture (n = 2/2) 1 cycle after the His-refractory PVC was specifically diagnostic. Exceptionally, the disappearance of the reset phenomenon was also observed in the two cNVP-ORTs. Step 3 was verification of the AVN as the cNVP insertion site, evidenced by an atrial reset/block preceding the His reset/block in fast-slow AVNRT with a cNVP-SP and slow-fast AVNRT with a cNVP-FP or His reset preceding the atrial reset in slow-fast AVNRT with a cNVP-SP. Conclusion AVNRT with a bystander cNVP can be diagnosed in the three steps with few exceptions. Notably, tachycardia reset/termination without atrial capture one cycle after delivery of a His-refractory PVC is specifically diagnostic.
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Affiliation(s)
- Koichi Nagashima
- Division of Cardiology, Department of MedicineNihon University School of MedicineTokyoJapan
| | - Mitsunori Maruyama
- Department of Cardiovascular MedicineNippon Medical School Musashikosugi HospitalKanagawaJapan
| | - Yoshiaki Kaneko
- Department of Cardiovascular MedicineGunma University Graduate School of MedicineGunmaJapan
| | - Satoshi Sakai
- Department of CardiologyNara Prefecture General Medical CenterNaraJapan
| | - Takayuki Sekihara
- Department of Cardiovascular MedicineOsaka University Graduate School of MedicineOsakaJapan
| | - Tetsuma Kawaji
- Department of CardiologyMitsubishi Kyoto HospitalKyotoJapan
| | - Hidehiro Iwakawa
- Department of Cardiovascular MedicineAkita University Graduate School of MedicineAkitaJapan
| | | | - Chisato Ota
- Department of Cardiovascular MedicineNational Cerebral and Cardiovascular CenterOsakaJapan
| | - Satoshi Nagase
- Department of Advanced Arrhythmia and Translational Medical ScienceNational Cerebral and Cardiovascular CenterOsakaJapan
| | - Tetsuo Yagi
- Department of CardiologySendai City HospitalMiyagiJapan
| | | | - Hidehira Fukaya
- Department of Cardiovascular MedicineKitasato University School of MedicineKanagawaJapan
| | - Hironori Nakamura
- Department of Cardiovascular MedicineKitasato University School of MedicineKanagawaJapan
| | - Hitoshi Mori
- Department of CardiologySaitama Medical University International Medical CenterSaitamaJapan
| | - Akiko Ueda
- Division of Advance Arrhythmia ManagementKyorin University HospitalTokyoJapan
| | - Kyoko Soejima
- Department of Cardiovascular MedicineKyorin University HospitalTokyoJapan
| | - Ryuta Watanabe
- Division of Cardiology, Department of MedicineNihon University School of MedicineTokyoJapan
| | - Yuji Wakamatsu
- Division of Cardiology, Department of MedicineNihon University School of MedicineTokyoJapan
| | - Shu Hirata
- Division of Cardiology, Department of MedicineNihon University School of MedicineTokyoJapan
| | - Moyuru Hirata
- Division of Cardiology, Department of MedicineNihon University School of MedicineTokyoJapan
| | - Yasuo Okumura
- Division of Cardiology, Department of MedicineNihon University School of MedicineTokyoJapan
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Halder A, Vijay S, Kolamkar Y, Kumble YM, Lokhandwala Y. Clinical profile and electrophysiological characteristics of atypical atrioventricular nodal reentrant tachycardia: A decade's experience. Indian Pacing Electrophysiol J 2024; 24:25-29. [PMID: 37839730 PMCID: PMC10928009 DOI: 10.1016/j.ipej.2023.10.004] [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: 06/21/2023] [Revised: 10/08/2023] [Accepted: 10/13/2023] [Indexed: 10/17/2023] Open
Abstract
OBJECTIVE To assess the clinical features and inducibility characteristics of atypical atrioventricular nodal reentrant tachycardia (AVNRT) and compare it with typical AVNRT. BACKGROUND AVNRT is the commonest form of paroxysmal supraventricular tachycardia. The mechanism of AVNRT is very varied. Several classification systems evolved with better understanding but a simplified approach of classification into typical and atypical AVNRT is justifiable and clinically more relevant. In our study, we have assessed the epidemiological profile of atypical AVNRT in a single institute over 10 years and analysed pertinent electrophysiological characteristics. METHOD In this retrospective observational single center study we analysed data of all AVNRT cases from January 2011 to June 2021. In our study we classified atypical AVNRT and typical AVNRT based on the HA interval; HA≤70 ms in the His bundle region during tachycardia was considered as typical AVNRT. Other parameters were also analysed during tachycardia, such as: induction by atrial or ventricular pacing, AH/HA ratio, tachycardia cycle length and site of the earliest atrial activation. The demographic profile of the patients were also compared between 2 groups. RESULTS Atypical AVNRT was found in 75/1431 patients (5.2%) of all cases of AVNRT. The age of patients with atypical AVNRT was 52.4 ± 15.2 years (range 9-82 years) while that for typical AVNRT it was 48.2 ± 15.7 years (2-89 years), p = 0.023. There was no gender difference. Atypical AVNRT was induced by only ventricular extrastimuli (VES) in 17/75 (22.6%) while in typical AVNRT this was seen in only 12/1356 patients (0.9%, p < 0.001). Induction of atypical AVNRT was seen by both atrial extrastimuli (AES) and VES in 17/75 patients (22.6%) while in typical AVNRT this was seen in 64/1356 patients (4.8%, p < 0.001). Atypical AVNRT was induced by only AES in 40/75 patients (53.3%) while in typical AVNRT this was seen in 1280/1356 patients (94.3%, p < 0.001). An AH >200 ms during tachycardia was seen in all patients with typical AVNRT and in only 31/75 patients (41.3%) of atypical AVNRT (p < 0.00001). An interesting finding in atypical AVNRT was the earliest atrial activation at the His bundle region in 10/75 (13.3%) patients. CONCLUSION Atypical AVNRT prevalence depends on the way it is classified; this was 5.2% of all AVNRT cases in our study. Typical AVNRT was seen more frequently in comparatively younger age group and was more often induced by AES. Atypical AVNRT was much more commonly induced by only VES compared to typical AVNRT. It was not so unusual in atypical AVNRT to find the earliest atrial activation in the His bundle region.
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Affiliation(s)
- Ashesh Halder
- Department of Cardiology Medica Superspecialty Hospital, Kolkata, India.
| | | | - Yogesh Kolamkar
- Department of Cardiology, Holy Family Hospital, Mumbai, India
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Wang NC. Incessant typical atrioventricular nodal reentrant tachycardia with prolonged PR interval during sinus rhythm: Case report and literature review. HeartRhythm Case Rep 2023; 9:826-831. [PMID: 38023684 PMCID: PMC10667120 DOI: 10.1016/j.hrcr.2023.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023] Open
Affiliation(s)
- Norman C. Wang
- Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Ryzhii M, Ryzhii E. A compact multi-functional model of the rabbit atrioventricular node with dual pathways. Front Physiol 2023; 14:1126648. [PMID: 36969598 PMCID: PMC10036810 DOI: 10.3389/fphys.2023.1126648] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Accepted: 02/22/2023] [Indexed: 03/12/2023] Open
Abstract
The atrioventricular node (AVN) is considered a “black box”, and the functioning of its dual pathways remains controversial and not fully understood. In contrast to numerous clinical studies, there are only a few mathematical models of the node. In this paper, we present a compact, computationally lightweight multi-functional rabbit AVN model based on the Aliev-Panfilov two-variable cardiac cell model. The one-dimensional AVN model includes fast (FP) and slow (SP) pathways, primary pacemaking in the sinoatrial node, and subsidiary pacemaking in the SP. To obtain the direction-dependent conduction properties of the AVN, together with gradients of intercellular coupling and cell refractoriness, we implemented the asymmetry of coupling between model cells. We hypothesized that the asymmetry can reflect some effects related to the complexity of the real 3D structure of AVN. In addition, the model is accompanied by a visualization of electrical conduction in the AVN, revealing the interaction between SP and FP in the form of ladder diagrams. The AVN model demonstrates broad functionality, including normal sinus rhythm, AVN automaticity, filtering of high-rate atrial rhythms during atrial fibrillation and atrial flutter with Wenckebach periodicity, direction-dependent properties, and realistic anterograde and retrograde conduction curves in the control case and the cases of FP and SP ablation. To show the validity of the proposed model, we compare the simulation results with the available experimental data. Despite its simplicity, the proposed model can be used both as a stand-alone module and as a part of complex three-dimensional atrial or whole heart simulation systems, and can help to understand some puzzling functions of AVN.
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Affiliation(s)
- Maxim Ryzhii
- Department of Computer Science and Engineering, University of Aizu, Aizu-Wakamatsu, Japan
- *Correspondence: Maxim Ryzhii ,
| | - Elena Ryzhii
- Department of Anatomy and Histology, Fukushima Medical University, Fukushima, Japan
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9
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Tchou P, Nemer D, Saliba W, Varma N, Aziz P, Patel A, Nakagawa H, Kanj M, Hussein A, Bhargava M, Wazni O. Junctional Tachycardia. JACC Clin Electrophysiol 2023; 9:425-441. [PMID: 36990601 DOI: 10.1016/j.jacep.2022.10.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 10/17/2022] [Accepted: 10/26/2022] [Indexed: 02/24/2023]
Abstract
Junctional tachycardia (JT) is typically considered to have an automatic mechanism originating from the distal atrioventricular node. When there is 1:1 retrograde conduction via the fast pathway, JT would resemble the typical form of atrioventricular nodal re-entrant tachycardia (AVNRT). Atrial pacing maneuvers have been proposed to exclude AVNRT and suggest a diagnosis of JT. However, after excluding AVNRT, one should consider the possibility of an infra-atrial narrow QRS re-entrant tachycardia, which can exhibit features that resemble AVNRT as well as JT. Pacing maneuvers and mapping techniques should be performed to assess for infra-atrial re-entrant tachycardia before concluding that JT is the mechanism of a narrow QRS tachycardia. Distinguishing JT from typical AVNRT or infra-atrial re-entrant tachycardia has notable implications regarding the approach to ablation of the tachycardia. Ultimately, a contemporary review of the evidence on JT raises some questions as to the mechanism and source of what has traditionally been considered JT.
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Effect of Direct Slow Pathway Capture Mapping-Guided Ablation on Typical Atrioventricular Nodal Re-Entrant Tachycardia. JACC Clin Electrophysiol 2023; 9:209-218. [PMID: 36858687 DOI: 10.1016/j.jacep.2022.08.029] [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: 05/04/2022] [Revised: 08/24/2022] [Accepted: 08/29/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Direct slow pathway capture (DSPC) mapping is a novel electrophysiological technique for detecting antegrade slow pathway input sites. However, the effect of DSPC mapping-guided ablation on atrioventricular nodal re-entrant tachycardia (AVNRT) is unknown. OBJECTIVES This study aimed to evaluate the efficacy and safety of DSPC mapping-guided ablation in typical AVNRT patients. METHODS A multicenter retrospective study was conducted in 301 consecutive typical AVNRT patients. The outcomes in patients who underwent DSPC mapping-guided ablation (DSPC group) and those who underwent conventional anatomical ablation (conventional group) were compared. The conventional group was established before introducing DSPC mapping-guided ablation. Positive DSPC sites were defined as sites with a return cycle atrioventricular prolongation of ≥20 ms with high-output (10-20 V) pacing during tachycardia or the last paced beat of the atrial extrastimulation. RESULTS Among 116 patients in the DSPC group, 102 (88%) had positive DSPC sites, and 86 (74%) had a successful ablation at that site. Of the remaining 30 patients, 27 had a successful anatomical ablation. The DSPC group had a significantly lower frequency of radiofrequency applications and shorter total application time than the conventional group (median: 5.5 [IQR: 3-11] times vs 9 [IQR: 5-15] times, and 168 [IQR: 108-266] seconds vs 244 [IQR: 158-391] seconds, respectively; P < 0.01). Moreover, the DSPC group had a numerically lower incidence of permanent pacemaker implantations and AVNRT recurrences than the conventional group (0% vs 1.6%; P = 0.17, and 1.7% vs 3.2%; P = 0.43, respectively). CONCLUSIONS DSPC mapping-guided ablation was associated with a lower operative time, which can reduce the risk of AV conduction injury in typical AVNRT.
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Spontaneous Variation of Ventriculo-Atrial Interval after Tachycardia Induction: Determinants and Usefulness in the Diagnosis of Supraventricular Tachycardias with Long Ventriculoatrial Interval. J Clin Med 2023; 12:jcm12020409. [PMID: 36675339 PMCID: PMC9864055 DOI: 10.3390/jcm12020409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 12/26/2022] [Accepted: 12/31/2022] [Indexed: 01/06/2023] Open
Abstract
Background: Determining the mechanism of supraventricular tachycardias with prolongedP ventriculoatrial (VA) intervals is sometimes a challenge. Our objective is to analyse the determinants, time course and diagnostic accuracy (atypical atrioventricular nodal reentrant tachycardias [AVNRT] versus orthodromic reentrant tachycardias through an accessory pathway [ORT]) of spontaneous VA intervals variation in patients with narrow QRS tachycardias and prolonged VA. Methods: A total of 156 induced tachycardias were studied (44 with atypical AVNRT and 112 with ORT). Two sets of 10 measurements were performed for each patient—after tachycardia induction and one minute later. VA and VV intervals were determined. Results: The difference between the longest and the shortest VA interval (Dif-VA) correlates significantly with the diagnosis of atypical AVNRT (C coefficient = 0.95 and 0.85 after induction and at one minute, respectively; p < 0.001). A Dif-VA ≥ 15 ms presents a sensitivity and specificity for atypical AVNRT of 50% and 99%, respectively after induction, and of 27% and 100% one minute later. We found a robust and significant correlation between the fluctuations of VV and VA intervals in atypical AVNRTs (Coefficient Rho: 0.56 and 0.76, after induction and at one minute, respectively; p < 0.001 for both) but not in ORTs. Conclusions: The analysis of VA interval variability after induction and one minute later correctly discriminates atypical AVNRT from ORT in almost all cases.
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Hadid C, Celano L, Di Toro D, Antezana-Chavez E, Gallino S, Iralde G, Calvo D, Ávila P, Atea L, Gonzalez S, Maldonado S, Labadet C. Variability of the VA interval at tachycardia induction: a simple method to differentiate orthodromic reciprocating tachycardia from atypical atrioventricular nodal reentrant tachycardia. J Interv Card Electrophysiol 2022; 66:637-645. [PMID: 36152135 DOI: 10.1007/s10840-022-01376-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Accepted: 09/13/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND The differential diagnosis between orthodromic atrioventricular reentry tachycardia (AVRT) and atypical AV nodal reentrant tachycardia (aAVNRT) is sometimes challenging. We hypothesize that aAVNRTs have more variability in the retrograde conduction time at tachycardia onset than AVRTs. METHODS We aimed to assess the variability in retrograde conduction time at tachycardia onset in AVRT and aAVNRT and to propose a new diagnostic tool to differentiate these two arrhythmia mechanisms. We measured the VA interval of the first beats after tachycardia induction until it stabilized. The difference between the maximum and minimum VA intervals (∆VA) and the number of beats needed for the VA interval to stabilize was analyzed. Atrial tachycardias were excluded. RESULTS A total of 107 patients with aAVNRT (n = 37) or AVRT (n = 64) were included. Six additional patients with decremental accessory pathway-mediated tachycardia (DAPT) were analyzed separately. All aAVNRTs had VA interval variability. The median ∆VA was 0 (0 - 5) ms in AVRTs vs 40 (21 - 55) ms in aAVNRTs (p < 0.001). The VA interval stabilized significantly earlier in AVRTs (median 1.5 [1 - 3] beats) than in aAVNRTs (5 [4 - 7] beats; p < 0.001). A ∆VA < 10 ms accurately differentiated AVRT from aAVNRT with 100% of sensitivity, specificity, and positive and negative predictive values. The stabilization of the VA interval at < 3 beats of the tachycardia onset identified AVRT with sensitivity, specificity, and positive and negative predictive values of 64.1%, 94.6%, 95.3%, and 60.3%, respectively. A ∆VA < 20 ms yielded good diagnostic accuracy for DAPT. CONCLUSIONS A ∆VA < 10 ms is a simple and useful criterion that accurately distinguished AVRT from atypical AVNRT. Central panel: Scatter plot showing individual values of ∆VA in atypical AVNRT and AVRT. Left panel: induction of atypical AVNRT. The VA interval stabilizes at the 5th beat and the ∆VA is 62 ms (maximum VA interval: 172 ms - minimum VA interval: 110 ms). Right panel: induction of AVRT. The tachycardia has a fixed VA interval from the first beat. ∆VA is 0 ms.
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Affiliation(s)
- Claudio Hadid
- Hospital General de Agudos Dr. Cosme Argerich, Pi y Margall 750, 1155, Ciudad Autónoma de Buenos Aires, Argentina. .,Hospital Universitario CEMIC, Ciudad Autónoma de Buenos Aires, Argentina. .,Sanatorio Garat, Concordia, Entre Ríos, Argentina. .,Cardiovascular Chivilcoy, Chivilcoy, Buenos Aires, Argentina.
| | - Leonardo Celano
- Hospital General de Agudos Dr. Cosme Argerich, Pi y Margall 750, 1155, Ciudad Autónoma de Buenos Aires, Argentina.,Hospital Universitario CEMIC, Ciudad Autónoma de Buenos Aires, Argentina
| | - Darío Di Toro
- Hospital General de Agudos Dr. Cosme Argerich, Pi y Margall 750, 1155, Ciudad Autónoma de Buenos Aires, Argentina.,Hospital Universitario CEMIC, Ciudad Autónoma de Buenos Aires, Argentina
| | - Edgar Antezana-Chavez
- Hospital General de Agudos Dr. Cosme Argerich, Pi y Margall 750, 1155, Ciudad Autónoma de Buenos Aires, Argentina
| | | | - Gustavo Iralde
- Cardiovascular Chivilcoy, Chivilcoy, Buenos Aires, Argentina
| | - David Calvo
- Arrhythmia Unit, Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria de Asturias, Oviedo, Spain
| | - Pablo Ávila
- Cardiology Department, Hospital General Universitario Gregorio Marañon, Instituto de Investigación Sanitaria Gregorio Marañon, Madrid, Spain.,Centre for Biomedical Research in Cardiovascular Disease Network (CIBERCV), Madrid, Spain
| | | | | | | | - Carlos Labadet
- Hospital General de Agudos Dr. Cosme Argerich, Pi y Margall 750, 1155, Ciudad Autónoma de Buenos Aires, Argentina.,Hospital Universitario CEMIC, Ciudad Autónoma de Buenos Aires, Argentina
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Jansen H, Nürnberg JH, Veltmann C, Hebe J. Anatomy for ablation of atrioventricular nodal reentry tachycardia and accessory pathways. Herzschrittmacherther Elektrophysiol 2022; 33:133-147. [PMID: 35608665 DOI: 10.1007/s00399-022-00860-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 04/17/2022] [Indexed: 11/26/2022]
Abstract
The atrioventricular (AV) valve plane and the central septum are of particular importance for electrophysiological diagnosis and interventional therapy of supraventricular tachycardias because accessory electrical connections of various types may be present in addition to the specific conduction system. Although modern 3D electroanatomic reconstruction systems including high-density mapping can be of great assistance, detailed knowledge of the anatomic structures involved, their complex three-dimensional arrangement, and their electrical properties in conjunction with electrophysiological features of supraventricular arrhythmias is essential for safe and efficient electrophysiological treatment. The aim of this article is to present current anatomical, topographical, and electrophysiological findings against the background of historical, seminal, and still indispensable literature.
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14
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Howard TS, Valdes SO, Zobeck MC, Lam WW, Miyake CY, Rochelson E, Dan Pham T, Kim JJ. Ripple Mapping: A precise tool for atrioventricular nodal reentrant tachycardia ablation. J Cardiovasc Electrophysiol 2022; 33:1183-1189. [PMID: 35419906 DOI: 10.1111/jce.15491] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/16/2022] [Accepted: 04/11/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Ablation for atrioventricular nodal reentrant tachycardia (AVNRT) classically utilizes evaluation of signal morphology within the anatomic region of the slow pathway (SP), which involves subjectivity. Ripple Mapping (RM) (CARTO-3© Biosense Webster Inc, Irvine, CA) displays each electrogram at its 3-dimensional coordinate as a bar changing in length according to its voltage-time relationship. This allows prolonged, low-amplitude signals to be displayed in their entirety, helping identify propagation in low-voltage areas. We set out to evaluate the ability of RM to locate the anatomic site of the slow pathway and assess its use in guiding ablation for AVNRT. METHODS Patients ≤18 yrs with AVNRT in the EP laboratory between 2017 and 2021 were evaluated. RM was performed to define region of SP conduction in patients from 2019-2021, whereas standard electro-anatomical mapping was used from 2017-2019. All ablations were performed using cryo-therapy. Demographics, outcomes and analysis of variance in number of test lesions until success were compared between groups. RESULTS A total 115 patients underwent AVRNT ablation during the study; 46 patients were in the RM group and 69 were in the control group. There were no demographic differences between groups. All procedures, in both groups, were acutely successful. In RM group, 89% of first successful lesions were within 4mm of the predicted site. There was significantly reduced variability in number of test lesions until success in the RM group (p=0.01). CONCLUSIONS RM is a novel technique that can help identify slow pathway location, allowing for successful ablation of AVNRT with decreased variability. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Taylor S Howard
- Department of Pediatrics, Division of Pediatric Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Santiago O Valdes
- Department of Pediatrics, Division of Pediatric Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Mark C Zobeck
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Wilson W Lam
- Department of Pediatrics, Division of Pediatric Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Christina Y Miyake
- Department of Pediatrics, Division of Pediatric Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA.,Department of Molecular Physiology and Biophysics, Baylor College of Medicine, Houston, Tx, USA
| | - Ellis Rochelson
- Department of Pediatrics, Division of Pediatric Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Tam Dan Pham
- Department of Pediatrics, Division of Pediatric Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Jeffrey J Kim
- Department of Pediatrics, Division of Pediatric Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
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15
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De Roy L, Deceuninck O, Carryn X, Dechaux D. Reply to Letter to the Editor - Narrow QRS tachycardia with AV response from 2:1 to 1:1. What is the mechanism? Acta Cardiol 2022:1. [PMID: 35166195 DOI: 10.1080/00015385.2022.2040826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Luc De Roy
- Service de cardiologie CHR de Namur, Namur, Belgique
| | | | - Xavier Carryn
- Service de cardiologie CHR de Namur, Namur, Belgique
| | - David Dechaux
- Service de cardiologie CHR de Namur, Namur, Belgique
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16
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Randomized trial of intracardiac echocardiography-guided slow pathway ablation. J Interv Card Electrophysiol 2022; 63:709-714. [PMID: 35044581 DOI: 10.1007/s10840-022-01126-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 01/13/2022] [Indexed: 10/19/2022]
Abstract
PURPOSE Radiofrequency (RF) catheter ablation of the slow pathway (SP) in atrioventricular nodal reentry tachycardia (AVNRT) is highly effective; however, it may require prolonged fluoroscopy and RF time. We postulated that visualization of the SP region with intracardiac echocardiography (ICE) could decrease ablation time, minimize radiation exposure, and facilitate SP ablation compared to the standard, fluoroscopy-guided approach. METHODS In our study, we randomized 91 patients undergoing electrophysiologic study and SP ablation for AVNRT into 2 groups: fluoroscopy-only (n = 48) or ICE-guided (n = 43) group. Crossover to ICE-guidance was allowed after 8 unsuccessful RF applications. RESULTS Mapping plus ablation time (mean ± standard deviation: 18.8 ± 16.1 min vs 11.6 ± 15.0 min, p = 0.031), fluoroscopy time (median [interquartile range]: 4.9 [2.93-8.13] min vs. 1.8 [1.2-2.8] min, p < 0.001), and total ablation time (144 [104-196] s vs. 81 [60-159] s, p = 0.001) were significantly shorter in the ICE group. ICE-guidance was associated with reduced radiation exposure (13.2 [8.2-13.4] mGy vs. 3.7 [1.5-5.8] mGy, p < 0.001). The sum of delivered RF energy (3866 [2786-5656] Ws vs. 2283 [1694-4284] Ws, p = 0.002) and number of RF applications (8 [4.25-12.75] vs. 4 [2-7], p = 0.001) were also lower with ICE-guidance. Twelve (25%) patients crossed over to the ICE-guided group. All were treated successfully thereafter with similar number, time, and cumulative energy of RF applications compared to the ICE group. No recurrence occurred during the follow-up. CONCLUSIONS ICE-guidance during SP ablation significantly reduces mapping and ablation time, radiation exposure, and RF delivery in comparison to fluoroscopy-only procedures. Moreover, early switching to ICE-guided ablation seems to be an optimal choice in challenging cases.
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17
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Sánchez-Quintana D, Anderson RH, Tretter JT, Cabrera JA, Sternick EB, Farré J. Anatomy of the conduction tissues 100 years on: what have we learned? Heart 2021; 108:1430-1437. [PMID: 34969873 DOI: 10.1136/heartjnl-2021-320304] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 11/30/2021] [Indexed: 11/04/2022] Open
Abstract
Knowledge of the anatomy of the 'conduction tissues' of the heart is a 20th century phenomenon. Although controversies still continue on the topic, most could have been avoided had greater attention been paid to the original descriptions. All cardiomyocytes, of course, have the capacity to conduct the cardiac impulse. The tissues specifically described as 'conducting' first generate the cardiac impulse, and then deliver it in such a fashion that the ventricles contract in orderly fashion. The tissues cannot readily be distinguished by gross inspection. Robust definitions for their recognition had been provided by the end of the first decade of the 20th century. These definitions retain their currency. The sinus node lies as a cigar-shaped structure subepicardially within the terminal groove. There is evidence that it is associated with a paranodal area that may have functional significance. Suggestions of dual nodes, however, are without histological confirmation. The atrioventricular node is located within the triangle of Koch, with significant inferior extensions occupying the atrial vestibules and with septal connections. The conduction axis penetrates the insulating plane of the atrioventricular junctions to continue as the ventricular pathways. Remnants of a ring of cardiomyocytes observed during development are also to be found within the atrial vestibules, particularly a prominent retroaortic remnant, although that their role has still to be determined. Application of the initial criteria for nodes and tracts shows that there are no special 'conducting tissues' in the pulmonary venous sleeves that might underscore the abnormal rhythm of atrial fibrillation.
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Affiliation(s)
| | - Robert H Anderson
- Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Justin T Tretter
- Heart Institute, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - José Angel Cabrera
- Department of Cardiology, Hospital Universitario Quirón-Madrid, European University of Madrid, Madrid, Spain
| | | | - Jerónimo Farré
- Madrid Autonomous University, Fundación Jiménez Díaz Hospital, Madrid, Spain
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18
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Drca N, von Olshausen G, Braunschweig F. Response to "Classification of AVNRT: An unresolved entity". J Cardiovasc Electrophysiol 2021; 33:323. [PMID: 34935235 DOI: 10.1111/jce.15322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 12/04/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Nikola Drca
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Gesa von Olshausen
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Frieder Braunschweig
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
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19
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Lokhandwala Y, Halder A. Classification of AVNRT: An unresolved entity. J Cardiovasc Electrophysiol 2021; 33:322. [PMID: 34910343 DOI: 10.1111/jce.15321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 11/18/2021] [Indexed: 11/30/2022]
Affiliation(s)
| | - Ashesh Halder
- Department of Cardiology, Desun Hospital, Kolkata, India
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20
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Anderson RH, Hikspoors JPJM, Tretter JT, Mac�as Y, Spicer DE, Lamers WH, S�nchez-Quintana D, Sternick EB. Inferior Extensions of the Atrioventricular Node. Arrhythm Electrophysiol Rev 2021; 10:262-272. [PMID: 35106179 PMCID: PMC8785076 DOI: 10.15420/aer.2021.43] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 09/02/2021] [Indexed: 12/29/2022] Open
Abstract
The pathways for excitation of the atrioventricular node enter either superiorly, as the so-called ‘fast’ pathway, or inferiorly as the ‘slow’ pathway. However, knowledge of the specific anatomical details of these pathways is limited. Most of the experimental studies that established the existence of these pathways were conducted in mammalian hearts, which have subtle differences to human hearts. In this review, the authors summarise their recent experiences investigating human cardiac development, correlating these results with the arrangement of the connections between the atrial myocardium and the compact atrioventricular node as revealed by serial sectioning of adult human hearts. They discuss the contributions made from the atrioventricular canal myocardium, as opposed to the primary ring. Both these rings are incorporated into the atrial vestibules, albeit with the primary ring contributing only to the tricuspid vestibule. The atrial septal cardiomyocytes are relatively late contributors to the nodal inputs. Finally, they relate our findings of human cardiac development to the postnatal arrangement.
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Affiliation(s)
- Robert H Anderson
- Biosciences Institute, Newcastle University, Newcastle-upon-Tyne, UK
| | - Jill PJM Hikspoors
- Department of Anatomy and Embryology, Maastricht University, Maastricht, the Netherlands
| | - Justin T Tretter
- Heart Institute, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, US
| | - Yolanda Mac�as
- Department of Human Anatomy and Cell Biology, Faculty of Medicine, University of Extremadura, Badajoz, Spain
| | - Diane E Spicer
- Congenital Heart Center, University of Florida, Gainesville, FL, US
- Heart Institute, Johns Hopkins All Children’s Hospital, St Petersburg, FL, US
| | - Wouter H Lamers
- Department of Anatomy and Embryology, Maastricht University, Maastricht, the Netherlands
| | - Dami�n S�nchez-Quintana
- Department of Human Anatomy and Cell Biology, Faculty of Medicine, University of Extremadura, Badajoz, Spain
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21
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Katritsis DG, Calkins H, Anderson RH. The Specialized Atrioventricular Ring Tissues Participate in the Circuit of Atrioventricular Nodal Reentrant Tachycardia. J Am Heart Assoc 2021; 10:e022811. [PMID: 34719243 PMCID: PMC8751966 DOI: 10.1161/jaha.121.022811] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | - Robert H Anderson
- Biosciences Institute Newcastle University Newcastle upon Tyne United Kingdom
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22
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von Olshausen G, Jemtrén A, Schwieler J, Tapanainen J, Bourke T, Paul-Nordin A, Benson L, Saluveer O, Kennebäck G, Braunschweig F, Drca N. Cryoablation of atypical atrioventricular nodal reentry tachycardia. J Cardiovasc Electrophysiol 2021; 32:2971-2978. [PMID: 34535930 DOI: 10.1111/jce.15244] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 08/13/2021] [Accepted: 09/06/2021] [Indexed: 12/29/2022]
Abstract
AIM Data on ablation for atypical recurrent atrioventricular nodal reentry tachycardia (AVNRT) and long-term follow-up are generally sparse. Furthermore, the rate of recurrence and safety of cryoablation for atypical AVNRT has not been established. We compared patients cryoablated for atypical AVNRT and typical AVNRT during long-term follow-up. METHODS All patients (n = 2612) who underwent catheter ablation for AVNRT at the Karolinska University Hospital between January 2009 and August 2019 were analyzed. A total of 91 patients undergoing first-time cryoablation for atypical AVNRT were included. A control group with first-time cryoablation for typical AVNRT was matched in a 1:1 ratio. Patients were followed-up for recurrences for a median of 5.0 years (interquartile range: 3.1-7.5 years). RESULTS After 5 years, AVNRT recurrence occurred in 10 patients (11.0%) in the atypical AVNRT group and in 8 patients (8.8%) in the typical AVNRT group (hazard ratio: 1.31 [95% confidence interval: 0.52-3.32]; p = 0.568). The duration of the index procedure was significantly longer for atypical compared to typical AVNRT ablation (132.1 ± 49.2 min vs. 110.1 ± 38.8 min; p = 0.001). Transient AV blocks occurred in a similar fashion in the atypical compared to typical group (11 [12.1%] vs. 4 [4.9%]; p = 0.103). However, no ablation induced persistent AV block developed in either group. CONCLUSION Cryoablation for atypical AVNRT showed similar rate of recurrences and safety compared to typical AVNRT during long-term follow-up.
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Affiliation(s)
- Gesa von Olshausen
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Anette Jemtrén
- Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden.,Department of Cardiology, St. Göran's Hospital, Stockholm, Sweden
| | - Jonas Schwieler
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Jari Tapanainen
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Tara Bourke
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Astrid Paul-Nordin
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Lina Benson
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Ott Saluveer
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Göran Kennebäck
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Frieder Braunschweig
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Nikola Drca
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
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Nogami A, Kurita T, Abe H, Ando K, Ishikawa T, Imai K, Usui A, Okishige K, Kusano K, Kumagai K, Goya M, Kobayashi Y, Shimizu A, Shimizu W, Shoda M, Sumitomo N, Seo Y, Takahashi A, Tada H, Naito S, Nakazato Y, Nishimura T, Nitta T, Niwano S, Hagiwara N, Murakawa Y, Yamane T, Aiba T, Inoue K, Iwasaki Y, Inden Y, Uno K, Ogano M, Kimura M, Sakamoto S, Sasaki S, Satomi K, Shiga T, Suzuki T, Sekiguchi Y, Soejima K, Takagi M, Chinushi M, Nishi N, Noda T, Hachiya H, Mitsuno M, Mitsuhashi T, Miyauchi Y, Miyazaki A, Morimoto T, Yamasaki H, Aizawa Y, Ohe T, Kimura T, Tanemoto K, Tsutsui H, Mitamura H. JCS/JHRS 2019 guideline on non-pharmacotherapy of cardiac arrhythmias. J Arrhythm 2021; 37:709-870. [PMID: 34386109 PMCID: PMC8339126 DOI: 10.1002/joa3.12491] [Citation(s) in RCA: 89] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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24
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Katritsis DG, Marine JE, Katritsis G, Latchamsetty R, Zografos T, Zimetbaum P, Buxton AE, Calkins H, Morady F, Sánchez-Quintana D, Anderson RH. Spatial characterization of the tachycardia circuit of atrioventricular nodal re-entrant tachycardia. Europace 2021; 23:1596-1602. [PMID: 34240123 DOI: 10.1093/europace/euab130] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 05/04/2021] [Indexed: 11/13/2022] Open
Abstract
AIMS The exact circuit of atrioventricular nodal re-entrant tachycardia (AVNRT) remains elusive. To assess the location and dimensions of the AVNRT circuit. METHODS AND RESULTS Both typical and atypical AVNRT were induced at electrophysiology study of 14 patients. We calculated the activation time of the fast and slow pathways, and consequently, the length of the slow pathway, by assuming an average conduction velocity of 0.04 mm/ms in the nodal area. The distance between the compact atrioventricular node and the slow pathway ablating electrode was measured on three-dimensionally reconstructed fluoroscopic images obtained in diastole and systole. We also measured the length of the histologically discrete right inferior nodal extension in 31 human hearts. The length of the slow pathway was calculated to be 10.8 ± 1.3 mm (range 8.2-12.8 mm). The distance from the node to the ablating electrode was measured in five patients 17.0 ± 1.6 mm (range 14.9-19.2 mm) and was consistently longer than the estimated length of the slow pathway (P < 0.001). The length of the right nodal inferior extension in histologic specimens was 8.1 ± 2.3 mm (range 5.3-13.7 mm). There were no statistically significant differences between these values and the calculated slow pathway lengths. CONCLUSION Successful ablation affects the tachycardia circuit without necessarily abolishing slow conduction, probably by interrupting the circuit at the septal isthmus.
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Affiliation(s)
- Demosthenes G Katritsis
- Hygeia Hospital, 4 Erythrou Stavrou Str, Athens 15123, Greece.,Johns Hopkins Hospital, Baltimore, MD, USA
| | | | | | | | | | - Peter Zimetbaum
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Alfred E Buxton
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | | | - Damián Sánchez-Quintana
- Department of Anatomy and Cell Biology, Faculty of Medicine, University of Extremadura, Badajoz, Spain
| | - Robert H Anderson
- Biosciences Institute, Newcastle University, Newcastle upon Tyne, UK
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25
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Catheter ablation via the left atrium for atrioventricular nodal reentrant tachycardia: A narrative review. Heart Rhythm O2 2021; 2:187-200. [PMID: 34113921 PMCID: PMC8183875 DOI: 10.1016/j.hroo.2021.01.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Since 1996, it has been recognized that catheter ablation for atrioventricular nodal reentrant tachycardia (AVNRT) may require an approach through the left atrium. Objective The purposes are to present a case report and to provide a comprehensive narrative review on this topic. Methods A literature review of all articles that provided detailed information on patients who underwent catheter ablation via the left atrium for AVNRT was performed. The primary search queried PubMed using Medical Subject Headings (MeSH) terms "atrioventricular nodal reentrant tachycardia" and "left." The secondary search was performed by manual review of reference lists and Google Scholar citations of manuscripts retrieved by the primary search. The review was limited to the English language. Results The searches yielded 30 articles that described 79 patients. A case report was added. Therefore, the final review consisted of 80 patients. The prevalence of left atrial ablation for patients with AVNRT undergoing catheter ablation at tertiary care centers was approximately 1%. Failed right atrial ablation, with or without coronary sinus ablation, was the most common indication for left atrial ablation. Pooled data from 3 cohort studies estimated the acute success rate for radiofrequency ablation of the slow pathway at the septal or inferoparaseptal segments of the mitral valve annulus after failed right-sided ablation to be 90%. There were no reports of atrioventricular block requiring permanent pacemaker implantation. Conclusion Catheter ablation of the slow pathway via the left atrium is an important technique for AVNRT cases that are refractory to conventional ablation.
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Nogami A, Kurita T, Abe H, Ando K, Ishikawa T, Imai K, Usui A, Okishige K, Kusano K, Kumagai K, Goya M, Kobayashi Y, Shimizu A, Shimizu W, Shoda M, Sumitomo N, Seo Y, Takahashi A, Tada H, Naito S, Nakazato Y, Nishimura T, Nitta T, Niwano S, Hagiwara N, Murakawa Y, Yamane T, Aiba T, Inoue K, Iwasaki Y, Inden Y, Uno K, Ogano M, Kimura M, Sakamoto SI, Sasaki S, Satomi K, Shiga T, Suzuki T, Sekiguchi Y, Soejima K, Takagi M, Chinushi M, Nishi N, Noda T, Hachiya H, Mitsuno M, Mitsuhashi T, Miyauchi Y, Miyazaki A, Morimoto T, Yamasaki H, Aizawa Y, Ohe T, Kimura T, Tanemoto K, Tsutsui H, Mitamura H. JCS/JHRS 2019 Guideline on Non-Pharmacotherapy of Cardiac Arrhythmias. Circ J 2021; 85:1104-1244. [PMID: 34078838 DOI: 10.1253/circj.cj-20-0637] [Citation(s) in RCA: 77] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Akihiko Nogami
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | | | - Haruhiko Abe
- Department of Heart Rhythm Management, University of Occupational and Environmental Health, Japan
| | - Kenji Ando
- Department of Cardiology, Kokura Memorial Hospital
| | - Toshiyuki Ishikawa
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University
| | - Katsuhiko Imai
- Department of Cardiovascular Surgery, Kure Medical Center and Chugoku Cancer Center
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
| | - Kaoru Okishige
- Department of Cardiology, Yokohama City Minato Red Cross Hospital
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | | | - Masahiko Goya
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University
| | | | | | - Wataru Shimizu
- Department of Cardiovascular Medicine, Graduate School of Medicine, Nippon Medical School
| | - Morio Shoda
- Department of Cardiology, Tokyo Women's Medical University
| | - Naokata Sumitomo
- Department of Pediatric Cardiology, Saitama Medical University International Medical Center
| | - Yoshihiro Seo
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | | | - Hiroshi Tada
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui
| | | | - Yuji Nakazato
- Department of Cardiovascular Medicine, Juntendo University Urayasu Hospital
| | - Takashi Nishimura
- Department of Cardiac Surgery, Tokyo Metropolitan Geriatric Hospital
| | - Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School
| | - Shinichi Niwano
- Department of Cardiovascular Medicine, Kitasato University School of Medicine
| | | | - Yuji Murakawa
- Fourth Department of Internal Medicine, Teikyo University Hospital Mizonokuchi
| | - Teiichi Yamane
- Department of Cardiology, Jikei University School of Medicine
| | - Takeshi Aiba
- Division of Arrhythmia, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Koichi Inoue
- Division of Arrhythmia, Cardiovascular Center, Sakurabashi Watanabe Hospital
| | - Yuki Iwasaki
- Department of Cardiovascular Medicine, Graduate School of Medicine, Nippon Medical School
| | - Yasuya Inden
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Kikuya Uno
- Arrhythmia Center, Chiba Nishi General Hospital
| | - Michio Ogano
- Department of Cardiovascular Medicine, Shizuoka Medical Center
| | - Masaomi Kimura
- Advanced Management of Cardiac Arrhythmias, Hirosaki University Graduate School of Medicine
| | | | - Shingo Sasaki
- Department of Cardiology and Nephrology, Hirosaki University Graduate School of Medicine
| | | | - Tsuyoshi Shiga
- Department of Cardiology, Tokyo Women's Medical University
| | - Tsugutoshi Suzuki
- Departments of Pediatric Electrophysiology, Osaka City General Hospital
| | - Yukio Sekiguchi
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | - Kyoko Soejima
- Arrhythmia Center, Second Department of Internal Medicine, Kyorin University Hospital
| | - Masahiko Takagi
- Division of Cardiac Arrhythmia, Department of Internal Medicine II, Kansai Medical University
| | - Masaomi Chinushi
- School of Health Sciences, Faculty of Medicine, Niigata University
| | - Nobuhiro Nishi
- Department of Cardiovascular Therapeutics, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Takashi Noda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Hitoshi Hachiya
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital
| | | | | | - Yasushi Miyauchi
- Department of Cardiovascular Medicine, Nippon Medical School Chiba-Hokusoh Hospital
| | - Aya Miyazaki
- Department of Pediatric Cardiology, Congenital Heart Disease Center, Tenri Hospital
| | - Tomoshige Morimoto
- Department of Thoracic and Cardiovascular Surgery, Osaka Medical College
| | - Hiro Yamasaki
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | | | | | - Takeshi Kimura
- Department of Cardiology, Graduate School of Medicine and Faculty of Medicine, Kyoto University
| | - Kazuo Tanemoto
- Department of Cardiovascular Surgery, Kawasaki Medical School
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Brugada J, Katritsis DG, Arbelo E, Arribas F, Bax JJ, Blomström-Lundqvist C, Calkins H, Corrado D, Deftereos SG, Diller GP, Gomez-Doblas JJ, Gorenek B, Grace A, Ho SY, Kaski JC, Kuck KH, Lambiase PD, Sacher F, Sarquella-Brugada G, Suwalski P, Zaza A. 2019 ESC Guidelines for the management of patients with supraventricular tachycardiaThe Task Force for the management of patients with supraventricular tachycardia of the European Society of Cardiology (ESC). Eur Heart J 2021; 41:655-720. [PMID: 31504425 DOI: 10.1093/eurheartj/ehz467] [Citation(s) in RCA: 522] [Impact Index Per Article: 174.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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28
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Sugumar H, Chieng D, Prabhu S, Voskoboinik A, Anderson RD, Al-Kaisey A, Lee G, McLellan AJ, Morton JB, Taylor AJ, Ling LH, Kalman JM, Kistler PM. A prospective evaluation of the impact of individual RF applications for slow pathway ablation for AVNRT: Markers of acute success. J Cardiovasc Electrophysiol 2021; 32:1886-1893. [PMID: 33855753 DOI: 10.1111/jce.15045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 02/25/2021] [Accepted: 03/19/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Catheter ablation is highly effective for atrioventricular nodal re-entrant tachycardia (AVNRT). Generally junctional rhythm (JR) is an accepted requirement for successful ablation however there is a lack of detailed prospective studies to determine the characteristics of JR and the impact on slow pathway conduction. METHODS Multicentre prospective observational study evaluating the impact of individual radiofrequency (RF) applications in typical AVNRT (slow/fast). Characteristics of JR during ablation were documented and detailed testing was performed after every RF application to determine outcome. Procedural success was defined as ≤1 AV nodal echo. RESULTS Sixty-seven patients were included (mean age 53 ± 18years, 57% female and a history of SVT 2.9 ± 4.7 years). RF (50w, 60°) ablation for AVNRT was applied in 301 locations with JR in 178 (59%). Successful slow pathway modification was achieved in 66 (99%) patients with slow pathway block in 30 (46%). Success was associated with JR in all patients. Success was achieved in six patients with RF < 10 s. There was no significant difference in the CL of JR during RF between effective (587 ± 150 ms) versus ineffective (611 ± 193 ms, p = .4) applications. Inadvertent junctional beat-atrial (JA) block with immediate termination of RF was observed in 19 (28%) patients with AVNRT no longer inducible in 14 (74%). Freedom from SVT was achieved in 66 (99%) patients at a mean follow up of 15 ± 6 months. CONCLUSION In this prospective study, JR was required during RF for acute success in AVNRT. Cycle length of JR during RF was not predictive of success. Although unintended JA block during faster JR was associated with slow pathway block, this is a precursor to fast pathway block and should not be intentionally targeted.
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Affiliation(s)
- Hariharan Sugumar
- Department of Cardiology, The Baker Heart & Diabetes Institute, Melbourne, Australia.,Department of Cardiology, The Alfred Hospital, Melbourne, Australia.,Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia.,Department of Medicine, University of Melbourne, Melbourne, Australia
| | - David Chieng
- Department of Cardiology, The Baker Heart & Diabetes Institute, Melbourne, Australia.,Department of Cardiology, The Alfred Hospital, Melbourne, Australia.,Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia.,Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Sandeep Prabhu
- Department of Cardiology, The Baker Heart & Diabetes Institute, Melbourne, Australia.,Department of Cardiology, The Alfred Hospital, Melbourne, Australia
| | - Aleksandr Voskoboinik
- Department of Cardiology, The Baker Heart & Diabetes Institute, Melbourne, Australia.,Department of Cardiology, The Alfred Hospital, Melbourne, Australia
| | - Robert D Anderson
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia.,Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Ahmed Al-Kaisey
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia.,Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Geoffrey Lee
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia.,Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Alex J McLellan
- Department of Cardiology, The Baker Heart & Diabetes Institute, Melbourne, Australia.,Department of Cardiology, The Alfred Hospital, Melbourne, Australia.,Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia.,Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Joseph B Morton
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia.,Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Andrew J Taylor
- Department of Cardiology, The Baker Heart & Diabetes Institute, Melbourne, Australia.,Department of Cardiology, The Alfred Hospital, Melbourne, Australia.,Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Liang-Han Ling
- Department of Cardiology, The Baker Heart & Diabetes Institute, Melbourne, Australia.,Department of Cardiology, The Alfred Hospital, Melbourne, Australia.,Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Jonathan M Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia.,Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Peter M Kistler
- Department of Cardiology, The Baker Heart & Diabetes Institute, Melbourne, Australia.,Department of Cardiology, The Alfred Hospital, Melbourne, Australia.,Department of Medicine, University of Melbourne, Melbourne, Australia.,Department of Medicine, Monash University, Melbourne, Australia
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29
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Katritsis DG. A unified theory for the circuit of atrioventricular nodal re-entrant tachycardia. Europace 2020; 22:1763-1767. [DOI: 10.1093/europace/euaa196] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 06/17/2020] [Indexed: 01/04/2023] Open
Abstract
Abstract
Atrioventricular nodal re-entrant tachycardia (AVNRT) is the most common regular tachycardia in the human, but its exact circuit remains elusive. In this article, recent evidence about the electrophysiological characteristics of AVNRT and new data on the anatomy of the atrioventricular node, are discussed. Based on this information, a novel, unified theory for the nature of the circuit of the tachycardia is presented.
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30
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Pinos J, Luz Leiria TL, Kruse ML, Pires LM, De Lima GG. “Kiss of the girl from Ipanema” and syncope: A variant presentation of atrioventricular nodal reentrant tachycardia. HeartRhythm Case Rep 2020; 6:610-613. [PMID: 32983877 PMCID: PMC7498519 DOI: 10.1016/j.hrcr.2020.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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31
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32
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[Catheter ablation of supraventricular tachycardia]. Herzschrittmacherther Elektrophysiol 2019; 30:336-342. [PMID: 31713026 DOI: 10.1007/s00399-019-00654-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: 09/13/2019] [Accepted: 10/11/2019] [Indexed: 10/25/2022]
Abstract
Supraventricular tachycardias (SVT) are common, with atrioventricular nodal reentry tachycardias (AVNRT) being the most common paroxysmal supraventricular tachycardia. The pathophysiological understanding and the catheter ablation of SVTs have developed steadily in recent years. For example, dividing AVNRT into "typical" and "atypical" depending on the HA-, VA-interval and AH/HA ratio is recommended. Because of higher rates of recurrences after cryoablation, radiofrequency ablation has prevailed in AVNRT. The current ESC guidelines for SVTs recommend the ablation of accessory pathways in asymptomatic high-risk patients and it is now a Class I recommendation. There is no recommendation for the access in left-sided accessory pathways. However, a transseptal compared to transaortic approach seems more promising in acute success. The use of a three-dimensional (3D) mapping system leads to a reduction of the fluoroscopy times and procedure duration. Ablation of focal atrial tachycardia remains challenging despite the use of 3D electroanatomical mapping systems. However, new technologies such as high-density (HD) multipoint mapping systems can be helpful. HD mapping systems also allow a better understanding of left and right atrial macroreentry tachycardia after previous ablation or cardiac surgery and in primary nature. However, in all technological advances, a proficient understanding of the basic techniques in electrophysiology, such as entrainment mapping, is mandatory.
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33
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Okishige K, Shigeta T, Nakamura RA, Hirao T, Yoshida H, Yamauchi Y. Lower common pathway location detected by cryoablation of atrioventricular nodal reentrant tachycardia of the common variety. Clin Case Rep 2019; 7:2202-2206. [PMID: 31788279 PMCID: PMC6878096 DOI: 10.1002/ccr3.2392] [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: 05/11/2019] [Revised: 07/15/2019] [Accepted: 08/06/2019] [Indexed: 11/07/2022] Open
Abstract
As different from radiofrequency current energy, cryofreezing energy is able to provide reversible effects on cardiac tissue, called "cryomapping," which enables us to predict the effects of a subsequent application of ablative energy. Cryomapping is able to delineate the anatomical location of the lower common pathway of atrioventricular nodal reentrant tachycardia.
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Affiliation(s)
- Kaoru Okishige
- Heart CenterJapan Red Cross Yokohama City Bay HospitalYokohamaJapan
| | | | - Rena A. Nakamura
- Heart CenterJapan Red Cross Yokohama City Bay HospitalYokohamaJapan
| | - Tatsuhiko Hirao
- Heart CenterJapan Red Cross Yokohama City Bay HospitalYokohamaJapan
| | - Hiroshi Yoshida
- Heart CenterJapan Red Cross Yokohama City Bay HospitalYokohamaJapan
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34
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Miljoen H, Ector J, Garweg C, Saenen J, Huybrechts W, Sarkozy A, Willems R, Heidbuchel H. Differential presentation of atrioventricular nodal re-entrant tachycardia in athletes and non-athletes. Europace 2019; 21:944-949. [DOI: 10.1093/europace/euz001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 01/03/2019] [Indexed: 01/02/2023] Open
Affiliation(s)
- Hielko Miljoen
- Department of Cardiology, University Hospital Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgium
| | | | | | - Johan Saenen
- Department of Cardiology, University Hospital Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgium
- University of Antwerp, Antwerp, Belgium
| | - Wim Huybrechts
- Department of Cardiology, University Hospital Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgium
- University of Antwerp, Antwerp, Belgium
| | - Andrea Sarkozy
- Department of Cardiology, University Hospital Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgium
- University of Antwerp, Antwerp, Belgium
| | | | - Hein Heidbuchel
- Department of Cardiology, University Hospital Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgium
- University of Antwerp, Antwerp, Belgium
- Hasselt University, Hasselt, Belgium
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35
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Endpoints for Successful Slow Pathway Catheter Ablation in Typical and Atypical Atrioventricular Nodal Re-Entrant Tachycardia. JACC Clin Electrophysiol 2019; 5:113-119. [DOI: 10.1016/j.jacep.2018.09.012] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 08/31/2018] [Accepted: 09/05/2018] [Indexed: 11/21/2022]
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36
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Katritsis DG. Catheter Ablation of Atrioventricular Nodal Re-entrant Tachycardia: Facts and Fiction. Arrhythm Electrophysiol Rev 2018; 7:230-231. [PMID: 30588309 PMCID: PMC6304791 DOI: 10.15420/aer.2018.7.4.eo1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 10/24/2018] [Indexed: 11/04/2022] Open
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37
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Katritsis DG, Boriani G, Cosio FG, Hindricks G, Jaïs P, Josephson ME, Keegan R, Kim YH, Knight BP, Kuck KH, Lane DA, Lip GYH, Malmborg H, Oral H, Pappone C, Themistoclakis S, Wood KA, Blomström-Lundqvist C, Gorenek B, Dagres N, Dan GA, Vos MA, Kudaiberdieva G, Crijns H, Roberts-Thomson K, Lin YJ, Vanegas D, Caorsi WR, Cronin E, Rickard J. European Heart Rhythm Association (EHRA) consensus document on the management of supraventricular arrhythmias, endorsed by Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulación Cardiaca y Electrofisiologia (SOLAECE). Europace 2018; 19:465-511. [PMID: 27856540 DOI: 10.1093/europace/euw301] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Affiliation(s)
- Demosthenes G Katritsis
- Athens Euroclinic, Athens, Greece; and Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Giuseppe Boriani
- Cardiology Department, Modena University Hospital, University of Modena and Reggio Emilia, Modena, Italy
| | | | | | - Pierre Jaïs
- University of Bordeaux, CHU Bordeaux, LIRYC, France
| | | | - Roberto Keegan
- Hospital Privado del Sur y Hospital Español, Bahia Blanca, Argentina
| | - Young-Hoon Kim
- Korea University Medical Center, Seoul, Republic of Korea
| | | | | | - Deirdre A Lane
- Asklepios Hospital St Georg, Hamburg, Germany.,University of Birmingham Institute of Cardiovascular Science, City Hospital, Birmingham, UK; and Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Gregory Y H Lip
- University of Birmingham Institute of Cardiovascular Science, City Hospital, Birmingham, UK; and Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Helena Malmborg
- Department of Cardiology and Medical Science, Uppsala University, Uppsala, Sweden
| | - Hakan Oral
- University of Michigan, Ann Arbor, MI, USA
| | - Carlo Pappone
- IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | | | | | | | - Bulent Gorenek
- Cardiology Department, Eskisehir Osmangazi University, Eskisehir, Turkey
| | | | - Gheorge-Andrei Dan
- Colentina University Hospital, 'Carol Davila' University of Medicine, Bucharest, Romania
| | - Marc A Vos
- Department of Medical Physiology, Division Heart and Lungs, Umc Utrecht, The Netherlands
| | | | - Harry Crijns
- Mastricht University Medical Centre, Cardiology & CARIM, The Netherlands
| | | | | | - Diego Vanegas
- Hospital Militar Central - Unidad de Electrofisiologìa - FUNDARRITMIA, Bogotà, Colombia
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38
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Sledz J, Labus M, Mazij M, Klank-Szafran M, Karbarz D, Ludwik B, Kusa J, Deutsch K, Szydlowski L, Mscisz A, Spikowski J, Morka A, Kameczura T, Swietoniowska-Mscisz A, Stec S. A simplified approach for evaluating sustained slow pathway conduction for diagnosis and treatment of atrioventricular nodal reentry tachycardia in children and adults. Adv Med Sci 2018; 63:249-256. [PMID: 29433068 DOI: 10.1016/j.advms.2018.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 01/05/2018] [Accepted: 01/08/2018] [Indexed: 11/17/2022]
Abstract
PURPOSE During incremental atrial pacing in patients with atrioventricular nodal reentrant tachycardia, the PR interval often exceeds the RR interval (PR > RR) during stable 1:1 AV conduction. However, the PR/RR ratio has never been evaluated in a large group of patients with pacing from the proximal coronary sinus and after isoproterenol challenge. Our study validates new site of pacing and easier method of identification of PR > RR. MATERIAL AND METHODS A prospective protocol of incremental atrial pacing from the proximal coronary sinus was carried out in 398 patients (AVNRT-228 and control-170). The maximum stimulus to the Q wave interval (S-Q = PR), SS interval (S-S), and Q-Q (RR) interval were measured at baseline and 10 min after successful slow pathway ablation and after isoproterenol challenge (obligatory). RESULTS The mean maximum PR/RR ratios at baseline were 1.17 ± 0.24 and 0.82 ± 0.13 (p < 0.00001) in the AVNRT and controls respectively. There were no PR/RR ratios ≥1 at baseline and after isoproterenol challenge in 12.3% of the AVNRT group and in 95.9% of the control group (p < 0.0001). PR/RR ratios ≥1 were absent in 98% of AVNRT cases after slow pathway ablation/modification in children and 99% of such cases in adults (P = NS). The diagnostic performance of PR/RR ratio evaluation before and after isoproterenol challenge had the highest diagnostic performance for AVNRT with PR/RR > = 1 (sensitivity: 88%, specificity: 96%, PPV-97%, NPV-85%). CONCLUSIONS The PR/RR ratio is a simple tool for slow pathway substrate and AVNRT evaluation. Eliminating PR/RR ratios ≥1 may serve as a surrogate endpoint for slow pathway ablation in children and adults with AVNRT.
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Affiliation(s)
- Janusz Sledz
- Elmedica, EP-Network, Kielce, Poland; Department of Cardiology, G.V.M. Carint, Ostrowiec Swietokrzyski, Poland; Carint Medica, EP-Network, Cracow, Poland
| | - Michal Labus
- Department of Cardiology, Regional Specialist Hospital, Centre for Research and Development, Wroclaw, Poland
| | - Mariusz Mazij
- Department of Cardiology, Regional Specialist Hospital, Centre for Research and Development, Wroclaw, Poland
| | | | | | - Bartosz Ludwik
- Department of Cardiology, Regional Specialist Hospital, Centre for Research and Development, Wroclaw, Poland
| | - Jacek Kusa
- Department of Cardiology, Regional Specialist Hospital, Centre for Research and Development, Wroclaw, Poland
| | | | - Leslaw Szydlowski
- Department of Pediatric Cardiology, Medical University of Silesia, Katowice, Poland
| | - Adrian Mscisz
- Chair of Electroradiology, Faculty of Medicine, University of Rzeszow, Rzeszow, Poland
| | - Jerzy Spikowski
- Department of Cardiology, Regional Specialist Hospital, Centre for Research and Development, Wroclaw, Poland
| | - Aleksandra Morka
- Department of Pediatric Cardiosurgery and Cardiosurgical Intensive Care University Children Hospital, Faculty of Health Sciences Jagiellonian University Medical College, Krakow, Poland.
| | - Tomasz Kameczura
- Podkarpackie Center for Cardiovascular Intervention, G.V.M. Carint, Sanok, Poland; Chair of Electroradiology, Faculty of Medicine, University of Rzeszow, Rzeszow, Poland
| | | | - Sebastian Stec
- Elmedica, EP-Network, Kielce, Poland; Chair of Electroradiology, Faculty of Medicine, University of Rzeszow, Rzeszow, Poland; Podkarpackie Center for Cardiovascular Intervention, G.V.M. Carint, Sanok, Poland
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39
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Katritsis DG, John RM, Latchamsetty R, Muthalaly RG, Zografos T, Katritsis GD, Stevenson WG, Efimov IR, Morady F. Left Septal Slow Pathway Ablation for Atrioventricular Nodal Reentrant Tachycardia. Circ Arrhythm Electrophysiol 2018. [DOI: 10.1161/circep.117.005907] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Demosthenes G. Katritsis
- From the Hygeia Hospital, Athens, Greece (D.G.K., T.Z.); Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (R.M.J., R.G.M., W.G.S.); University of Michigan Health System, Ann Arbor (R.L., F.M.); Imperial University Hospitals NHS Trust, London, United Kingdom (G.D.K.); and Biomedical Engineering, The George Washington University, Washington, DC (I.R.E.)
| | - Roy M. John
- From the Hygeia Hospital, Athens, Greece (D.G.K., T.Z.); Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (R.M.J., R.G.M., W.G.S.); University of Michigan Health System, Ann Arbor (R.L., F.M.); Imperial University Hospitals NHS Trust, London, United Kingdom (G.D.K.); and Biomedical Engineering, The George Washington University, Washington, DC (I.R.E.)
| | - Rakesh Latchamsetty
- From the Hygeia Hospital, Athens, Greece (D.G.K., T.Z.); Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (R.M.J., R.G.M., W.G.S.); University of Michigan Health System, Ann Arbor (R.L., F.M.); Imperial University Hospitals NHS Trust, London, United Kingdom (G.D.K.); and Biomedical Engineering, The George Washington University, Washington, DC (I.R.E.)
| | - Rahul G. Muthalaly
- From the Hygeia Hospital, Athens, Greece (D.G.K., T.Z.); Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (R.M.J., R.G.M., W.G.S.); University of Michigan Health System, Ann Arbor (R.L., F.M.); Imperial University Hospitals NHS Trust, London, United Kingdom (G.D.K.); and Biomedical Engineering, The George Washington University, Washington, DC (I.R.E.)
| | - Theodoros Zografos
- From the Hygeia Hospital, Athens, Greece (D.G.K., T.Z.); Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (R.M.J., R.G.M., W.G.S.); University of Michigan Health System, Ann Arbor (R.L., F.M.); Imperial University Hospitals NHS Trust, London, United Kingdom (G.D.K.); and Biomedical Engineering, The George Washington University, Washington, DC (I.R.E.)
| | - George D. Katritsis
- From the Hygeia Hospital, Athens, Greece (D.G.K., T.Z.); Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (R.M.J., R.G.M., W.G.S.); University of Michigan Health System, Ann Arbor (R.L., F.M.); Imperial University Hospitals NHS Trust, London, United Kingdom (G.D.K.); and Biomedical Engineering, The George Washington University, Washington, DC (I.R.E.)
| | - William G. Stevenson
- From the Hygeia Hospital, Athens, Greece (D.G.K., T.Z.); Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (R.M.J., R.G.M., W.G.S.); University of Michigan Health System, Ann Arbor (R.L., F.M.); Imperial University Hospitals NHS Trust, London, United Kingdom (G.D.K.); and Biomedical Engineering, The George Washington University, Washington, DC (I.R.E.)
| | - Igor R. Efimov
- From the Hygeia Hospital, Athens, Greece (D.G.K., T.Z.); Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (R.M.J., R.G.M., W.G.S.); University of Michigan Health System, Ann Arbor (R.L., F.M.); Imperial University Hospitals NHS Trust, London, United Kingdom (G.D.K.); and Biomedical Engineering, The George Washington University, Washington, DC (I.R.E.)
| | - Fred Morady
- From the Hygeia Hospital, Athens, Greece (D.G.K., T.Z.); Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (R.M.J., R.G.M., W.G.S.); University of Michigan Health System, Ann Arbor (R.L., F.M.); Imperial University Hospitals NHS Trust, London, United Kingdom (G.D.K.); and Biomedical Engineering, The George Washington University, Washington, DC (I.R.E.)
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Romero J, Kumar S, Akira F, Briceño DF, Tedrow UB, Epstein L, John R, Stevenson WG, Michaud GF. Emergence of atrioventricular nodal reentry tachycardia after surgical or catheter ablation for atrial fibrillation: Are we creating the arrhythmia substrate? Heart Rhythm 2017; 14:1637-1646. [DOI: 10.1016/j.hrthm.2017.08.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Indexed: 11/25/2022]
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Tchou P. Inflammation, scarring, and atrioventricular nodal reentrant tachycardia. Heart Rhythm 2017; 14:1647-1648. [PMID: 28843421 DOI: 10.1016/j.hrthm.2017.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Indexed: 11/25/2022]
Affiliation(s)
- Patrick Tchou
- Section of Cardiac Electrophysiology and Pacing, Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
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Miller JM. Mark E Josephson: Clinical Investigator. Arrhythm Electrophysiol Rev 2017; 6:9-12. [PMID: 28507738 DOI: 10.15420/aer.2017.6.1:ed3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Mark E Josephson entered the world of clinical cardiac electrophysiology (EP) almost at its inception (1972); with so much to learn and so many directions one could take, he dived into the field with unbridled enthusiasm and an uncommon - perhaps almost unique - aptitude for asking questions and finding ways to answer them. Few aspects of EP escaped his indelible influence. In this short paper, I will attempt to touch on some of the high points of his astounding career as a clinical investigator.
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Affiliation(s)
- John M Miller
- Indiana University School of Medicine; Indiana University Health, Indianapolis, USA
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George SA, Faye NR, Murillo-Berlioz A, Lee KB, Trachiotis GD, Efimov IR. At the Atrioventricular Crossroads: Dual Pathway Electrophysiology in the Atrioventricular Node and its Underlying Heterogeneities. Arrhythm Electrophysiol Rev 2017; 6:179-185. [PMID: 29326832 DOI: 10.15420/aer.2017.30.1] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
The atrioventricular node (AVN) is a complex structure that performs a variety of functions in the heart. The AVN is primarily an electrical gatekeeper between the atria and ventricles and introduces a delay between atrial and ventricular excitation, allowing for efficient ventricular filling. The AVN is composed of several compartments that safely transmit electrical excitation from the atria to the ventricles via the fast or slow pathways. There are many electrophysiological differences between these pathways, including conduction time and electrical refractoriness, that increase the predisposition of the atrioventricular junction to arrhythmias such as atrioventricular nodal re-entrant tachycardia. These varied electrophysiological characteristics of the fast and slow pathways stem from their unique structural and molecular composition (tissue and cellular geometry, ion channels and gap junctions). This review summarises the structural and molecular heterogeneities of the human AVN and how they result in electrophysiological variations and arrhythmias.
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Affiliation(s)
- Sharon A George
- Department of Biomedical Engineering, The George Washington University,Washington, DC, USA
| | - N Rokhaya Faye
- Department of Biomedical Engineering, The George Washington University,Washington, DC, USA
| | - Alejandro Murillo-Berlioz
- Department of Biomedical Engineering, The George Washington University,Washington, DC, USA.,Division of Cardiothoracic Surgery and Cardiothoracic Research, Veterans Affairs Medical Center,Washington, DC, USA
| | - K Benjamin Lee
- Department of Biomedical Engineering, The George Washington University,Washington, DC, USA.,Division of Cardiothoracic Surgery and Cardiothoracic Research, Veterans Affairs Medical Center,Washington, DC, USA
| | - Gregory D Trachiotis
- Division of Cardiothoracic Surgery and Cardiothoracic Research, Veterans Affairs Medical Center,Washington, DC, USA
| | - Igor R Efimov
- Department of Biomedical Engineering, The George Washington University,Washington, DC, USA
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Jackowska-Zduniak B, Forys U. Mathematical model of the atrioventricular nodal double response tachycardia and double-fire pathology. MATHEMATICAL BIOSCIENCES AND ENGINEERING : MBE 2016; 13:1143-1158. [PMID: 27775372 DOI: 10.3934/mbe.2016035] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
A proposed model consisting of two coupled models (Hodgkin-Huxley and Yanagihara-Noma-Irisawa model) is considered as a description of the heart's action potential. System of ordinary differential equations is used to recreate pathological behaviour in the conducting heart's system such as double fire and the most common tachycardia: atrioventricular nodal reentrant tachycardia (AVNRT). Part of the population has an abnormal accessory pathways: fast and slow (Fujiki, 2008). These pathways in the atrioventricular node (AV node) are anatomical and functional contributions of supraventricular tachycardia. However, the appearance of two pathways in the AV node may be a contribution of arrhythmia, which is caused by coexistent conduction by two pathways (called double fire). The difference in the conduction time between these pathways is the most important factor. This is the reason to introduce three types of couplings and delay to our system in order to reproduce various types of the AVNRT. In our research, introducing the feedback loops and couplings entails the creation of waves which can correspond to the re-entry waves occurring in the AVNRT. Our main aim is to study solutions of the given equations and take into consideration the influence of feedback and delays which occur in these pathological modes. We also present stability analysis for both components, that is Hodgkin-Huxley and Yanagihara-Noma-Irisawa models, as well as for the final double-fire model.
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Affiliation(s)
- Beata Jackowska-Zduniak
- Faculty of Applied Informatics and Mathematics, Warsaw University of Life Sciences, Nowoursynowska 159, 02-776 Warsaw, Poland.
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Katritsis DG, Marine JE, Contreras FM, Fujii A, Latchamsetty R, Siontis KC, Katritsis GD, Zografos T, John RM, Epstein LM, Michaud GF, Anter E, Sepahpour A, Rowland E, Buxton AE, Calkins H, Morady F, Stevenson WG, Josephson ME. Catheter Ablation of Atypical Atrioventricular Nodal Reentrant Tachycardia. Circulation 2016; 134:1655-1663. [DOI: 10.1161/circulationaha.116.024471] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 09/22/2016] [Indexed: 11/16/2022]
Abstract
Background:
Because of its low prevalence, data on atypical atrioventricular nodal reentrant tachycardia (AVNRT) are scarce, and the optimal ablation method has not been established. Our study aimed at assessing the efficacy and safety of conventional slow pathway ablation, as applied for typical cases, in atypical AVNRT.
Methods:
We studied 2079 patients with AVNRT subjected to slow pathway ablation. In 113 patients, mean age 48.5±18.1 years, 68 female, atypical AVNRT or coexistent atypical and typical AVNRT without other concomitant arrhythmia was diagnosed. Ablation data and outcomes were compared with a group of age- and sex-matched control patients with typical AVNRT.
Results:
Fluoroscopy and radiofrequency current delivery times were not different in the atypical and typical groups, 20.3±12.2 versus 20.8±12.9 minutes (
P
=0.730) and 5.9±5.0 versus 5.5±4.5 minutes (
P
=0.650), respectively. Slow pathway ablation was accomplished from the right septum in 110 patients, and from the left septum in 3 patients, in the atypical group. There was no need for additional ablation lesions at other anatomic sites, and no cases of atrioventricular block were encountered. Recurrence rates of the arrhythmia were 5.6% in the atypical (6/108 patients) and 1.8% in the typical (2/111 patients) groups in the next 3 months following ablation (
P
=0.167).
Conclusions:
Conventional ablation at the anatomic area of the slow pathway is the therapy of choice for symptomatic AVNRT, regardless of whether the typical or atypical form is present.
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Affiliation(s)
- Demosthenes G. Katritsis
- From Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (D.G.K., F.M.C., E.A., A.E.B., M.E.J.); Athens Euroclinic, Greece (D.G.K., T.Z.); Johns Hopkins Hospital, Baltimore, MD (J.E.M., H.C.); Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (A.F., R.M.J., L.M.E., G.F.M., W.G.S.); University of Michigan Health System, Ann Arbor (R.L., K.C.S., F.M.); The Oxford University Clinical Academic Graduate School, United Kingdom (G.D.K.); and The Heart Hospital, London,
| | - Joseph E. Marine
- From Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (D.G.K., F.M.C., E.A., A.E.B., M.E.J.); Athens Euroclinic, Greece (D.G.K., T.Z.); Johns Hopkins Hospital, Baltimore, MD (J.E.M., H.C.); Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (A.F., R.M.J., L.M.E., G.F.M., W.G.S.); University of Michigan Health System, Ann Arbor (R.L., K.C.S., F.M.); The Oxford University Clinical Academic Graduate School, United Kingdom (G.D.K.); and The Heart Hospital, London,
| | - Fernando M. Contreras
- From Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (D.G.K., F.M.C., E.A., A.E.B., M.E.J.); Athens Euroclinic, Greece (D.G.K., T.Z.); Johns Hopkins Hospital, Baltimore, MD (J.E.M., H.C.); Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (A.F., R.M.J., L.M.E., G.F.M., W.G.S.); University of Michigan Health System, Ann Arbor (R.L., K.C.S., F.M.); The Oxford University Clinical Academic Graduate School, United Kingdom (G.D.K.); and The Heart Hospital, London,
| | - Akira Fujii
- From Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (D.G.K., F.M.C., E.A., A.E.B., M.E.J.); Athens Euroclinic, Greece (D.G.K., T.Z.); Johns Hopkins Hospital, Baltimore, MD (J.E.M., H.C.); Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (A.F., R.M.J., L.M.E., G.F.M., W.G.S.); University of Michigan Health System, Ann Arbor (R.L., K.C.S., F.M.); The Oxford University Clinical Academic Graduate School, United Kingdom (G.D.K.); and The Heart Hospital, London,
| | - Rakesh Latchamsetty
- From Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (D.G.K., F.M.C., E.A., A.E.B., M.E.J.); Athens Euroclinic, Greece (D.G.K., T.Z.); Johns Hopkins Hospital, Baltimore, MD (J.E.M., H.C.); Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (A.F., R.M.J., L.M.E., G.F.M., W.G.S.); University of Michigan Health System, Ann Arbor (R.L., K.C.S., F.M.); The Oxford University Clinical Academic Graduate School, United Kingdom (G.D.K.); and The Heart Hospital, London,
| | - Konstantinos C. Siontis
- From Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (D.G.K., F.M.C., E.A., A.E.B., M.E.J.); Athens Euroclinic, Greece (D.G.K., T.Z.); Johns Hopkins Hospital, Baltimore, MD (J.E.M., H.C.); Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (A.F., R.M.J., L.M.E., G.F.M., W.G.S.); University of Michigan Health System, Ann Arbor (R.L., K.C.S., F.M.); The Oxford University Clinical Academic Graduate School, United Kingdom (G.D.K.); and The Heart Hospital, London,
| | - George D. Katritsis
- From Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (D.G.K., F.M.C., E.A., A.E.B., M.E.J.); Athens Euroclinic, Greece (D.G.K., T.Z.); Johns Hopkins Hospital, Baltimore, MD (J.E.M., H.C.); Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (A.F., R.M.J., L.M.E., G.F.M., W.G.S.); University of Michigan Health System, Ann Arbor (R.L., K.C.S., F.M.); The Oxford University Clinical Academic Graduate School, United Kingdom (G.D.K.); and The Heart Hospital, London,
| | - Theodoros Zografos
- From Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (D.G.K., F.M.C., E.A., A.E.B., M.E.J.); Athens Euroclinic, Greece (D.G.K., T.Z.); Johns Hopkins Hospital, Baltimore, MD (J.E.M., H.C.); Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (A.F., R.M.J., L.M.E., G.F.M., W.G.S.); University of Michigan Health System, Ann Arbor (R.L., K.C.S., F.M.); The Oxford University Clinical Academic Graduate School, United Kingdom (G.D.K.); and The Heart Hospital, London,
| | - Roy M. John
- From Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (D.G.K., F.M.C., E.A., A.E.B., M.E.J.); Athens Euroclinic, Greece (D.G.K., T.Z.); Johns Hopkins Hospital, Baltimore, MD (J.E.M., H.C.); Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (A.F., R.M.J., L.M.E., G.F.M., W.G.S.); University of Michigan Health System, Ann Arbor (R.L., K.C.S., F.M.); The Oxford University Clinical Academic Graduate School, United Kingdom (G.D.K.); and The Heart Hospital, London,
| | - Lawrence M. Epstein
- From Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (D.G.K., F.M.C., E.A., A.E.B., M.E.J.); Athens Euroclinic, Greece (D.G.K., T.Z.); Johns Hopkins Hospital, Baltimore, MD (J.E.M., H.C.); Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (A.F., R.M.J., L.M.E., G.F.M., W.G.S.); University of Michigan Health System, Ann Arbor (R.L., K.C.S., F.M.); The Oxford University Clinical Academic Graduate School, United Kingdom (G.D.K.); and The Heart Hospital, London,
| | - Gregory F. Michaud
- From Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (D.G.K., F.M.C., E.A., A.E.B., M.E.J.); Athens Euroclinic, Greece (D.G.K., T.Z.); Johns Hopkins Hospital, Baltimore, MD (J.E.M., H.C.); Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (A.F., R.M.J., L.M.E., G.F.M., W.G.S.); University of Michigan Health System, Ann Arbor (R.L., K.C.S., F.M.); The Oxford University Clinical Academic Graduate School, United Kingdom (G.D.K.); and The Heart Hospital, London,
| | - Elad Anter
- From Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (D.G.K., F.M.C., E.A., A.E.B., M.E.J.); Athens Euroclinic, Greece (D.G.K., T.Z.); Johns Hopkins Hospital, Baltimore, MD (J.E.M., H.C.); Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (A.F., R.M.J., L.M.E., G.F.M., W.G.S.); University of Michigan Health System, Ann Arbor (R.L., K.C.S., F.M.); The Oxford University Clinical Academic Graduate School, United Kingdom (G.D.K.); and The Heart Hospital, London,
| | - Ali Sepahpour
- From Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (D.G.K., F.M.C., E.A., A.E.B., M.E.J.); Athens Euroclinic, Greece (D.G.K., T.Z.); Johns Hopkins Hospital, Baltimore, MD (J.E.M., H.C.); Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (A.F., R.M.J., L.M.E., G.F.M., W.G.S.); University of Michigan Health System, Ann Arbor (R.L., K.C.S., F.M.); The Oxford University Clinical Academic Graduate School, United Kingdom (G.D.K.); and The Heart Hospital, London,
| | - Edward Rowland
- From Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (D.G.K., F.M.C., E.A., A.E.B., M.E.J.); Athens Euroclinic, Greece (D.G.K., T.Z.); Johns Hopkins Hospital, Baltimore, MD (J.E.M., H.C.); Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (A.F., R.M.J., L.M.E., G.F.M., W.G.S.); University of Michigan Health System, Ann Arbor (R.L., K.C.S., F.M.); The Oxford University Clinical Academic Graduate School, United Kingdom (G.D.K.); and The Heart Hospital, London,
| | - Alfred E. Buxton
- From Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (D.G.K., F.M.C., E.A., A.E.B., M.E.J.); Athens Euroclinic, Greece (D.G.K., T.Z.); Johns Hopkins Hospital, Baltimore, MD (J.E.M., H.C.); Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (A.F., R.M.J., L.M.E., G.F.M., W.G.S.); University of Michigan Health System, Ann Arbor (R.L., K.C.S., F.M.); The Oxford University Clinical Academic Graduate School, United Kingdom (G.D.K.); and The Heart Hospital, London,
| | - Hugh Calkins
- From Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (D.G.K., F.M.C., E.A., A.E.B., M.E.J.); Athens Euroclinic, Greece (D.G.K., T.Z.); Johns Hopkins Hospital, Baltimore, MD (J.E.M., H.C.); Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (A.F., R.M.J., L.M.E., G.F.M., W.G.S.); University of Michigan Health System, Ann Arbor (R.L., K.C.S., F.M.); The Oxford University Clinical Academic Graduate School, United Kingdom (G.D.K.); and The Heart Hospital, London,
| | - Fred Morady
- From Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (D.G.K., F.M.C., E.A., A.E.B., M.E.J.); Athens Euroclinic, Greece (D.G.K., T.Z.); Johns Hopkins Hospital, Baltimore, MD (J.E.M., H.C.); Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (A.F., R.M.J., L.M.E., G.F.M., W.G.S.); University of Michigan Health System, Ann Arbor (R.L., K.C.S., F.M.); The Oxford University Clinical Academic Graduate School, United Kingdom (G.D.K.); and The Heart Hospital, London,
| | - William G. Stevenson
- From Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (D.G.K., F.M.C., E.A., A.E.B., M.E.J.); Athens Euroclinic, Greece (D.G.K., T.Z.); Johns Hopkins Hospital, Baltimore, MD (J.E.M., H.C.); Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (A.F., R.M.J., L.M.E., G.F.M., W.G.S.); University of Michigan Health System, Ann Arbor (R.L., K.C.S., F.M.); The Oxford University Clinical Academic Graduate School, United Kingdom (G.D.K.); and The Heart Hospital, London,
| | - Mark E. Josephson
- From Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (D.G.K., F.M.C., E.A., A.E.B., M.E.J.); Athens Euroclinic, Greece (D.G.K., T.Z.); Johns Hopkins Hospital, Baltimore, MD (J.E.M., H.C.); Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (A.F., R.M.J., L.M.E., G.F.M., W.G.S.); University of Michigan Health System, Ann Arbor (R.L., K.C.S., F.M.); The Oxford University Clinical Academic Graduate School, United Kingdom (G.D.K.); and The Heart Hospital, London,
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Katritsis DG, Josephson ME. Classification, Electrophysiological Features and Therapy of Atrioventricular Nodal Reentrant Tachycardia. Arrhythm Electrophysiol Rev 2016; 5:130-5. [PMID: 27617092 DOI: 10.15420/aer.2016.18.2] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Atrioventricular nodal reentrant tachycardia (AVNRT) should be classified as typical or atypical. The term 'fast-slow AVNRT' is rather misleading. Retrograde atrial activation during tachycardia should not be relied upon as a diagnostic criterion. Both typical and atypical atrioventricular nodal reentrant tachycardia are compatible with varying retrograde atrial activation patterns. Attempts at establishing the presence of a 'lower common pathway' are probably of no practical significance. When the diagnosis of AVNRT is established, ablation should be only directed towards the anatomic position of the slow pathway. If right septal attempts are unsuccessful, the left septal side should be tried. Ablation targeting earliest atrial activation sites during typical atrioventricular nodal reentrant tachycardia or the fast pathway in general for any kind of typical or atypical atrioventricular nodal reentrant tachycardia, are not justified. In this review we discuss current concepts about the tachycardia circuit, electrophysiologic diagnosis, and ablation of this arrhythmia.
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Affiliation(s)
| | - Mark E Josephson
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Philip Saul J, Kanter RJ, Abrams D, Asirvatham S, Bar-Cohen Y, Blaufox AD, Cannon B, Clark J, Dick M, Freter A, Kertesz NJ, Kirsh JA, Kugler J, LaPage M, McGowan FX, Miyake CY, Nathan A, Papagiannis J, Paul T, Pflaumer A, Skanes AC, Stevenson WG, Von Bergen N, Zimmerman F. PACES/HRS expert consensus statement on the use of catheter ablation in children and patients with congenital heart disease. Heart Rhythm 2016; 13:e251-89. [DOI: 10.1016/j.hrthm.2016.02.009] [Citation(s) in RCA: 130] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Indexed: 11/15/2022]
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Nakatani Y, Mizumaki K, Sakamoto T, Kataoka N, Nishida K, Yamaguchi Y, Tsujino Y, Inoue H. Differentiation of Slow-Slow Form of AVNRT from AVRT through a Posteroseptal Accessory Pathway by Retrograde P-Wave Amplitude. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2015; 39:241-9. [PMID: 26643980 DOI: 10.1111/pace.12794] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 10/11/2015] [Accepted: 11/20/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND This study aimed to clarify whether retrograde P-wave amplitude during tachycardia can be used to differentiate slow-slow form of atrioventricular nodal reentrant tachycardia (S/S-AVNRT) from atrioventricular reentrant tachycardia through a posteroseptal accessory pathway (PS-AVRT). METHODS Sixteen patients with S/S-AVNRT and 14 patients with PS-AVRT constituted the study group. Electrocardiographic and electrophysiological parameters were compared between both the groups. HA(CS-His), which indicates the location of the earliest atrial activation site during tachycardia, was calculated as the difference of the shortest HA interval in the His bundle region and the coronary sinus region. RESULTS Negative deflection of the retrograde P wave during tachycardia was significantly greater in S/S-AVNRT than in PS-AVRT in the inferior leads (lead aVF, -0.22 ± 0.04 mV vs -0.10 ± 0.07 mV; P < 0.001). Among the electrocardiographic parameters, retrograde P-wave amplitude in lead aVF had the highest diagnostic accuracy (area under the curve 0.975, sensitivity 93%, and specificity 88% for a cutoff value of -0.16 mV). HA(CS-His) was negatively greater in S/S-AVNRT than in PS-AVRT (-24 ± 13 ms vs -3 ± 18 ms; P = 0.001), and was significantly correlated with the retrograde P-wave amplitude in lead aVF (P = 0.004). CONCLUSION Deeper negative deflection of the retrograde P wave in the inferior lead can help differentiate S/S-AVNRT from PS-AVRT.
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Affiliation(s)
- Yosuke Nakatani
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Koichi Mizumaki
- Clinical Research and Ethics Center, University of Toyama, Toyama, Japan
| | - Tamotsu Sakamoto
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Naoya Kataoka
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Kunihiro Nishida
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Yoshiaki Yamaguchi
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Yasushi Tsujino
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Hiroshi Inoue
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan
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Lin CH, Lin YJ, Chang SL, Lo LW, Huang HK, Chiang CH, Allamsetty S, Liao JN, Chung FP, Chang YT, Lin CY, Chen SA. Novel electrophysiological characteristics of atrioventricular nodal continuous conduction curves in atrioventricular nodal re-entrant tachycardia with concomitant cavotricuspid isthmus-dependent atrial flutter. Europace 2015; 18:1259-64. [PMID: 26612879 DOI: 10.1093/europace/euv345] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Accepted: 09/15/2015] [Indexed: 11/12/2022] Open
Abstract
AIMS The detailed electrophysiological characteristics of patients with both atrioventricular nodal re-entrant tachycardia (AVNRT) and atrial flutter (AFL) have not been clarified. This study investigated the related electrophysiological differences in a large series of patients undergoing radiofrequency catheter ablation of AVNRT. METHODS AND RESULTS A total of 1063 clinically documented AVNRT patients underwent catheter ablation were enrolled. Before the slow pathway (SP) ablation, 61 patients (5.7%) had inducible sustained cavotricuspid isthmus (CTI)-dependent AFL (Group 1), and the others (94.3%) without inducible sustained CTI-dependent AFL were defined as Group 2. The electrophysiological characteristics of these two groups and effect of the SP ablation on the inducibility of AFL were assessed. In Group 1, 36 patients (59%) had inducible/sustained AFL after the ablation of AVNRT and required a CTI ablation. The Group 1 patients had more AVNRT with continuous atrioventricular (AV) node function curves (P < 0.001, odds ratio = 7.55 [3.70-16.7], multivariate regression), and a younger age (P = 0.02, odds ratio = 1.02 [1.003-1.03], multivariate regression) than Group 2. The other characteristics were comparable between the two groups. The long-term follow-up (64.9 ± 34.9 months) revealed that the recurrence of AFL/atrial fibrillation was similar between the two groups (P > 0.05). CONCLUSION Atrioventricular nodal re-entrant tachycardia patients with concomitant CTI-dependent AFL had more continuous AV node function curves. Forty-one per cent of these patients had non-inducible AFL after the SP ablation, indicating a slow conduction isthmus in the triangle of Koch area.
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Affiliation(s)
- Chung-Hsing Lin
- Division of Cardiology, Taipei Veterans General Hospital, 201, Sec. 2, Shih-Pai Road, Taipei, Taiwan Faculty of Medicine, Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang-Ming University, Taipei, Taiwan Division of Cardiology, Taipei City Hospital, Ren-Ai Branch, Taipei, Taiwan
| | - Yenn-Jiang Lin
- Division of Cardiology, Taipei Veterans General Hospital, 201, Sec. 2, Shih-Pai Road, Taipei, Taiwan Faculty of Medicine, Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang-Ming University, Taipei, Taiwan
| | - Shih-Lin Chang
- Division of Cardiology, Taipei Veterans General Hospital, 201, Sec. 2, Shih-Pai Road, Taipei, Taiwan Faculty of Medicine, Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang-Ming University, Taipei, Taiwan
| | - Li-Wei Lo
- Division of Cardiology, Taipei Veterans General Hospital, 201, Sec. 2, Shih-Pai Road, Taipei, Taiwan Faculty of Medicine, Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang-Ming University, Taipei, Taiwan
| | - Hung-Kai Huang
- Division of Cardiology, Taipei Veterans General Hospital, 201, Sec. 2, Shih-Pai Road, Taipei, Taiwan Division of Cardiology, Department of Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Cheng-Hung Chiang
- Division of Cardiology, Taipei Veterans General Hospital, 201, Sec. 2, Shih-Pai Road, Taipei, Taiwan Division of Cardiology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Suresh Allamsetty
- Division of Cardiology, Taipei Veterans General Hospital, 201, Sec. 2, Shih-Pai Road, Taipei, Taiwan Nizam's Institute of Medical Science, Hyderabad, India
| | - Jo-Nan Liao
- Division of Cardiology, Taipei Veterans General Hospital, 201, Sec. 2, Shih-Pai Road, Taipei, Taiwan Faculty of Medicine, Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang-Ming University, Taipei, Taiwan
| | - Fa-Po Chung
- Division of Cardiology, Taipei Veterans General Hospital, 201, Sec. 2, Shih-Pai Road, Taipei, Taiwan Faculty of Medicine, Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang-Ming University, Taipei, Taiwan
| | - Yao-Ting Chang
- Division of Cardiology, Taipei Veterans General Hospital, 201, Sec. 2, Shih-Pai Road, Taipei, Taiwan Faculty of Medicine, Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang-Ming University, Taipei, Taiwan
| | - Chin-Yu Lin
- Division of Cardiology, Taipei Veterans General Hospital, 201, Sec. 2, Shih-Pai Road, Taipei, Taiwan Faculty of Medicine, Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang-Ming University, Taipei, Taiwan
| | - Shih-Ann Chen
- Division of Cardiology, Taipei Veterans General Hospital, 201, Sec. 2, Shih-Pai Road, Taipei, Taiwan Faculty of Medicine, Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang-Ming University, Taipei, Taiwan
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Katritsis DG, Josephson ME. Conduction over and around the atrioventricular node: author's reply. Europace 2015; 18:951-2. [PMID: 26564953 DOI: 10.1093/europace/euv348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Demosthenes G Katritsis
- Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, 185 Pilgrim Rd, Baker 4, Boston, MA 02215, USA
| | - Mark E Josephson
- Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, 185 Pilgrim Rd, Baker 4, Boston, MA 02215, USA
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