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[Ventriculoatrial block during tachycardia : A clearly defined electrophysiological criterion for an uncertain tachycardia]. Herzschrittmacherther Elektrophysiol 2021; 32:269-273. [PMID: 33944992 DOI: 10.1007/s00399-021-00768-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 04/11/2021] [Indexed: 10/21/2022]
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2
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Izumi G, Yokoshiki H, Sasaki R, Chiba Y, Yamazawa H, Takeda A. Fast pathway ablation unmasks nodoventricular fibers in a 15-year-old patient with supraventricular tachycardia. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2020; 44:395-398. [PMID: 33047312 DOI: 10.1111/pace.14088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 09/18/2020] [Accepted: 10/11/2020] [Indexed: 11/28/2022]
Abstract
We described a 15-year-old boy who underwent the catheter ablation for the nodoventricular (NV) tachycardia that had difficulty in differentiation from atrioventricular nodal reentrant tachycardia with upper common pathway. The modification of the fast pathway revealed an anterograde conduction of the NV fiber. We successfully performed the catheter ablation targeting for the right ventricular insertion site of the NV fiber.
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Affiliation(s)
- Gaku Izumi
- Department of Pediatrics, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Hisashi Yokoshiki
- Department of Cardiovascular Medicine, Sapporo City General Hospital, Sapporo, Japan
| | - Ryo Sasaki
- Division of Medical Engineering Center, Hokkaido University Hospital, Sapporo, Japan
| | - Yuki Chiba
- Division of Medical Engineering Center, Hokkaido University Hospital, Sapporo, Japan
| | - Hirokuni Yamazawa
- Department of Pediatrics, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Atsuhito Takeda
- Department of Pediatrics, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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Alasti M, Mirzaee S, Machado C, Healy S, Bittinger L, Adam D, Kotschet E, Krafchek J, Alison J. Junctional ectopic tachycardia (JET). J Arrhythm 2020; 36:837-844. [PMID: 33024461 PMCID: PMC7532275 DOI: 10.1002/joa3.12410] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 07/02/2020] [Accepted: 07/05/2020] [Indexed: 12/26/2022] Open
Abstract
Junctional ectopic tachycardia (JET) is a tachyarrhythmia arising from the atrioventricular node and His bundle area. Enhanced normal automaticity has been postulated as the mechanism of JET in the majority of patients. It is more common in children and can be seen as congenital or in postoperative settings. It is often a narrow complex tachycardia but can present as a wide complex tachycardia as a result of aberrant conduction. Its differentiation from other arrhythmias especially atrioventricular nodal reentrant tachycardia (AVNRT) can be challenging. Medical treatment of JET is difficult, and catheter ablation remains the mainstay of treatment in refractory cases with a high risk of atrioventricular block and recurrence.
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Affiliation(s)
- Mohammad Alasti
- Monash Cardiac Rhythm Management Department MonashHEART Monash Medical Centre Melbourne Vic. Australia
| | - Sam Mirzaee
- Monash Cardiac Rhythm Management Department MonashHEART Monash Medical Centre Melbourne Vic. Australia
| | - Colin Machado
- Monash Cardiac Rhythm Management Department MonashHEART Monash Medical Centre Melbourne Vic. Australia
| | - Stewart Healy
- Monash Cardiac Rhythm Management Department MonashHEART Monash Medical Centre Melbourne Vic. Australia
| | - Logan Bittinger
- Monash Cardiac Rhythm Management Department MonashHEART Monash Medical Centre Melbourne Vic. Australia
| | - David Adam
- Monash Cardiac Rhythm Management Department MonashHEART Monash Medical Centre Melbourne Vic. Australia
| | - Emily Kotschet
- Monash Cardiac Rhythm Management Department MonashHEART Monash Medical Centre Melbourne Vic. Australia
| | - Jack Krafchek
- Monash Cardiac Rhythm Management Department MonashHEART Monash Medical Centre Melbourne Vic. Australia
| | - Jeffrey Alison
- Monash Cardiac Rhythm Management Department MonashHEART Monash Medical Centre Melbourne Vic. Australia
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Bera D, Calambur N, Majumder S, Mukherjee SS. Interesting narrow complex tachycardia with regularly irregular RR intervals with more ventricular than atrial electrograms: What is the mechanism? J Cardiovasc Electrophysiol 2020; 31:2246-2252. [DOI: 10.1111/jce.14654] [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: 05/26/2020] [Revised: 07/01/2020] [Accepted: 07/04/2020] [Indexed: 11/30/2022]
Affiliation(s)
| | | | - Suchit Majumder
- Department of CardiologyApollo Gleneagles Hospital Kolkata India
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Cardona-Guarache R, Han FT, Nguyen DT, Chicos AB, Badhwar N, Knight BP, Johnson CJ, Heaven D, Scheinman MM. Ablation of Supraventricular Tachycardias From Concealed Left-Sided Nodoventricular and Nodofascicular Accessory Pathways. Circ Arrhythm Electrophysiol 2020; 13:e007853. [DOI: 10.1161/circep.119.007853] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Nodoventricular and nodofascicular accessory pathways (AP) are uncommon connections between the atrioventricular node and the fascicles or ventricles.
Methods:
Five patients with nodofascicular or nodoventricular tachycardia were studied.
Results:
We identified 5 patients with concealed, left-sided nodoventricular (n=4), and nodofascicular (n=1) AP. We proved the participation of AP in tachycardia by delivering His-synchronous premature ventricular contractions that either delayed the subsequent atrial electrogram or terminated the tachycardia (n=3), and by observing an increase in VA interval coincident with left bundle branch block (n=2). The APs were not atrioventricular pathways because the septal VA interval during tachycardia was <70 ms in 3, 1 had spontaneous atrioventricular dissociation, and in 1 the atria were dissociated from the circuit with atrial overdrive pacing. Entrainment from the right ventricle showed ventricular fusion in 4 out of 5 cases. A left-sided origin of the AP was suspected after failed ablation of the right inferior extension of atrioventricular node in 3 cases and by observing a VA increase with left bundle branch block in 2 cases. The nodofascicular and 3 of the nodoventricular AP were successfully ablated from within the proximal coronary sinus (CS) guided by recorded potentials at the roof of the CS, and 1 nodoventricular AP was ablated via a transseptal approach near the CS os.
Conclusions:
Left-sided nodofascicular and nodoventricular AP appear to connect the ventricles with the CS musculature in the region of the CS os. Mapping and successful ablation sites can be guided by recording potentials within or near the CS os.
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Affiliation(s)
- Ricardo Cardona-Guarache
- Division of Cardiology, University of California San Francisco, San Francisco, CA (R.C.-G., M.M.S.)
| | - Frederick T. Han
- Division of Cardiology, University of California San Diego, La Jolla (F.T.H.)
| | - Duy T. Nguyen
- Division of Cardiology, Stanford University, Palo Alto, CA (D.T.N., N.B.)
| | - Alexandru B. Chicos
- Division of Cardiology, Northwestern University, Chicago, IL (A.B.C., B.P.K.)
| | - Nitish Badhwar
- Division of Cardiology, Stanford University, Palo Alto, CA (D.T.N., N.B.)
| | - Bradley P. Knight
- Division of Cardiology, Northwestern University, Chicago, IL (A.B.C., B.P.K.)
| | | | - David Heaven
- Division of Cardiology, Middlemore Hospital, Auckland, NZ (D.H.)
| | - Melvin M. Scheinman
- Division of Cardiology, University of California San Francisco, San Francisco, CA (R.C.-G., M.M.S.)
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Soares Correa F, Lokhandwala Y, Sánchez-Quintana D, Mori S, Anderson RH, Wellens HJJ, Back Sternick E. Unusual variants of pre-excitation: From anatomy to ablation: Part III-Clinical presentation, electrophysiologic characteristics, when and how to ablate nodoventricular, nodofascicular, fasciculoventricular pathways, along with considerations of permanent junctional reciprocating tachycardia. J Cardiovasc Electrophysiol 2019; 30:3097-3115. [PMID: 31646696 DOI: 10.1111/jce.14247] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 09/24/2019] [Accepted: 10/12/2019] [Indexed: 11/30/2022]
Abstract
The recognition of the presence, location, and properties of unusual accessory pathways for atrioventricular conduction is an exciting, but frequently a difficult, challenge for the clinical cardiac arrhythmologist. In this third part of our series of reviews, we discuss the different steps required to come to the correct diagnosis and management decision in patients with nodofascicular, nodoventricular, and fasciculo-ventricular pathways. We also discuss the concealed accessory atrioventricular pathways with the properties of decremental retrograde conduction that are associated with the so-called permanent form of junctional reciprocating tachycardia. Careful analysis of the 12-lead electrocardiogram during sinus rhythm and tachycardias should always precede the investigation in the catheterization room. When using programmed electrical stimulation of the heart from different intracardiac locations, combined with activation mapping, it should be possible to localize both the proximal and distal ends of the accessory connections. This, in turn, should then permit the determination of their electrophysiologic properties, providing the answer to the question "are they incorporated in a tachycardia circuit?". It is this information that is essential for decision-making with regard to the need for catheter ablation, and if necessary, its appropriate site.
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Affiliation(s)
- Frederico Soares Correa
- Post Graduation Department, Faculdade de Ciências Médicas, Belo Horizonte, Brazil.,Arrhythmia and Electrophysiology Department, Biocor Institute, Nova Lima, Brazil
| | | | | | - Shumpei Mori
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Robert H Anderson
- Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Hein J J Wellens
- CARIM-Cardiovascular Research Centre Maastricht, Maastricht, The Netherlands
| | - Eduardo Back Sternick
- Post Graduation Department, Faculdade de Ciências Médicas, Belo Horizonte, Brazil.,Arrhythmia and Electrophysiology Department, Biocor Institute, Nova Lima, Brazil
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Iqbal M, Munawar M, Pramudya A, Karwiky G, Achmad C. Persistent VA dissociation during atrioventricular nodal reentry tachycardia: The existence of upper common pathway. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2019; 42:749-752. [PMID: 30609078 PMCID: PMC6850433 DOI: 10.1111/pace.13595] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 12/05/2018] [Accepted: 12/13/2018] [Indexed: 11/29/2022]
Abstract
The existence of the upper common pathways is not well-established yet. This case describes atrioventricular nodal reentry tachycardia with persistent ventriculoatrial dissociation that proof of upper common pathway existence.
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Affiliation(s)
- Mohammad Iqbal
- Department of Cardiology and Vascular Medicine, Universitas Padjadjaran, Bandung, Indonesia.,Binawaluya Cardiac Center, Jakarta, Indonesia
| | - Muhammad Munawar
- Department of Cardiology and Vascular Medicine, Universitas Padjadjaran, Bandung, Indonesia.,Binawaluya Cardiac Center, Jakarta, Indonesia
| | - Arsha Pramudya
- Department of Cardiology and Vascular Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Giky Karwiky
- Department of Cardiology and Vascular Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Chaerul Achmad
- Department of Cardiology and Vascular Medicine, Universitas Padjadjaran, Bandung, Indonesia
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Clinical Features and Sites of Ablation for Patients With Incessant Supraventricular Tachycardia From Concealed Nodofascicular and Nodoventricular Tachycardias. JACC Clin Electrophysiol 2017; 3:1547-1556. [PMID: 29759837 DOI: 10.1016/j.jacep.2017.07.015] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 06/22/2017] [Accepted: 07/13/2017] [Indexed: 02/07/2023]
Abstract
OBJECTIVES This study sought to describe the clinical features and sites of successful ablation for incessant nodofascicular (NF) and nodoventricular (NV) tachycardias. BACKGROUND Incessant supraventricular tachycardias have been associated with tachycardia-induced cardiomyopathies and have been previously attributed to permanent junctional reciprocating tachycardias, atrial tachycardias, and atrioventricular nodal re-entrant tachycardias. Incessant concealed NF and NV tachycardias have not been described previously. METHODS Three cases of incessant concealed NF and NV re-entrant tachycardias were identified from 2 centers. RESULTS The authors describe 3 cases with incessant supraventricular tachycardia resulting from NV (2 cases) and NF (1 case) pathways. Atrioventricular nodal re-entrant tachycardia was excluded by His synchronous premature ventricular complexes that either delayed or terminated the tachycardia. Ventricular pacing showed constant and progressive fusion in cases 1 and 3. In 2 cases, there was spontaneous initiation with a 1:2 response (cases 1 and 3); the presence of retrograde longitudinal dissociation or marked decremental pathway conduction in cases 1 and 3 sustains these tachycardias. The NV pathway was successfully ablated in the slow pathway region in case 3 and at the right bundle branch in case 1. The NF pathway was successfully ablated within the proximal coronary sinus in case 2. CONCLUSIONS This is the first report of incessant supraventricular tachycardia using concealed NF or NV pathways. These tachycardias demonstrated spontaneous initiation from sinus rhythm with a 1:2 response and retrograde longitudinal dissociation or marked decremental pathway conduction. Successful ablation was achieved at either right-sided sites or within the coronary sinus.
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Arora S. Incessant “ventricular tachycardia” in a patient with non-ischemic cardiomyopathy. What is the tachycardia mechanism? J Electrocardiol 2015; 48:455-7. [DOI: 10.1016/j.jelectrocard.2015.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Indexed: 11/29/2022]
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Hoffmayer KS, Lee BK, Vedantham V, Bhimani AA, Cakulev IT, Mackall JA, Sahadevan J, Rho RW, Scheinman MM. Variable clinical features and ablation of manifest nodofascicular/ventricular pathways. Circ Arrhythm Electrophysiol 2014; 8:117-27. [PMID: 25472957 DOI: 10.1161/circep.114.001924] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Manifest nodofascicular/ventricular (NFV) pathways are rare. METHODS AND RESULTS From 2008 to 2013, 4 cases were identified with manifest NFV pathways from 3 centers. The clinical findings and ablation sites are reported. All 4 cases presented with a wide complex tachycardia but with different QRS morphologies. Case 1 showed a left bundle branch block/superior axis, case 2 showed a right bundle branch block/inferior axis, case 3 showed a left bundle branch block/inferior axis, and case 4 showed a narrow QRS tachycardia and a wide complex tachycardia with a left bundle branch block/inferior axis. Three of the 4 tachycardias had atrioventricular dissociation ruling out extranodal accessory pathways, including atriofascicular pathways. Programmed extrastimuli showed evidence of a decremental accessory pathway in 3 of the 4 cases. Coexisting tachycardia mechanisms were seen in 3 of the 4 cases (atrioventricular nodal reentry tachycardia [2] and atrioventricular reentrant tachycardia [1]). Ablation in the slow pathway region eliminated the NFV pathway in 3 (transient in 1) with the other responding to surgical closure of a large atrial septal defect. The NFV pathway was a critical part of the tachycardia circuit in 1 and proved to be a bystander in the other 3 cases. CONCLUSIONS Manifest NFV pathways presented with variable QRS expression dependent on the ventricular insertion site and often coexisted with other tachycardia mechanisms (atrioventricular nodal reentry tachycardia and atrioventricular reentrant tachycardia). In most cases, the atrial insertion of the pathway was in or near the slow pathway region. The NFV pathways were either critical to the tachycardia circuit or served as bystanders.
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Affiliation(s)
- Kurt S Hoffmayer
- From the Division of Cardiovascular Medicine, Section of Electrophysiology, University of Wisconsin, Madison (K.S.H.); Division of Cardiovascular Medicine, Section of Electrophysiology, University of California, San Francisco (B.K.L., V.V., M.M.S.); Division of Cardiovascular Medicine, Department of Medicine, Harrington Heart Vascular Institute, University Hospitals Case Medical Center, Cleveland, OH (I.T.C., J.A.M., J.S.); Division of Cardiovascular Medicine, University of Texas Medical Branch, Galveston (A.A.B.); and Virginia Mason Medical Center, Seattle, WA (R.W.R.)
| | - Byron K Lee
- From the Division of Cardiovascular Medicine, Section of Electrophysiology, University of Wisconsin, Madison (K.S.H.); Division of Cardiovascular Medicine, Section of Electrophysiology, University of California, San Francisco (B.K.L., V.V., M.M.S.); Division of Cardiovascular Medicine, Department of Medicine, Harrington Heart Vascular Institute, University Hospitals Case Medical Center, Cleveland, OH (I.T.C., J.A.M., J.S.); Division of Cardiovascular Medicine, University of Texas Medical Branch, Galveston (A.A.B.); and Virginia Mason Medical Center, Seattle, WA (R.W.R.)
| | - Vasanth Vedantham
- From the Division of Cardiovascular Medicine, Section of Electrophysiology, University of Wisconsin, Madison (K.S.H.); Division of Cardiovascular Medicine, Section of Electrophysiology, University of California, San Francisco (B.K.L., V.V., M.M.S.); Division of Cardiovascular Medicine, Department of Medicine, Harrington Heart Vascular Institute, University Hospitals Case Medical Center, Cleveland, OH (I.T.C., J.A.M., J.S.); Division of Cardiovascular Medicine, University of Texas Medical Branch, Galveston (A.A.B.); and Virginia Mason Medical Center, Seattle, WA (R.W.R.)
| | - Ashish A Bhimani
- From the Division of Cardiovascular Medicine, Section of Electrophysiology, University of Wisconsin, Madison (K.S.H.); Division of Cardiovascular Medicine, Section of Electrophysiology, University of California, San Francisco (B.K.L., V.V., M.M.S.); Division of Cardiovascular Medicine, Department of Medicine, Harrington Heart Vascular Institute, University Hospitals Case Medical Center, Cleveland, OH (I.T.C., J.A.M., J.S.); Division of Cardiovascular Medicine, University of Texas Medical Branch, Galveston (A.A.B.); and Virginia Mason Medical Center, Seattle, WA (R.W.R.)
| | - Ivan T Cakulev
- From the Division of Cardiovascular Medicine, Section of Electrophysiology, University of Wisconsin, Madison (K.S.H.); Division of Cardiovascular Medicine, Section of Electrophysiology, University of California, San Francisco (B.K.L., V.V., M.M.S.); Division of Cardiovascular Medicine, Department of Medicine, Harrington Heart Vascular Institute, University Hospitals Case Medical Center, Cleveland, OH (I.T.C., J.A.M., J.S.); Division of Cardiovascular Medicine, University of Texas Medical Branch, Galveston (A.A.B.); and Virginia Mason Medical Center, Seattle, WA (R.W.R.)
| | - Judith A Mackall
- From the Division of Cardiovascular Medicine, Section of Electrophysiology, University of Wisconsin, Madison (K.S.H.); Division of Cardiovascular Medicine, Section of Electrophysiology, University of California, San Francisco (B.K.L., V.V., M.M.S.); Division of Cardiovascular Medicine, Department of Medicine, Harrington Heart Vascular Institute, University Hospitals Case Medical Center, Cleveland, OH (I.T.C., J.A.M., J.S.); Division of Cardiovascular Medicine, University of Texas Medical Branch, Galveston (A.A.B.); and Virginia Mason Medical Center, Seattle, WA (R.W.R.)
| | - Jayakumar Sahadevan
- From the Division of Cardiovascular Medicine, Section of Electrophysiology, University of Wisconsin, Madison (K.S.H.); Division of Cardiovascular Medicine, Section of Electrophysiology, University of California, San Francisco (B.K.L., V.V., M.M.S.); Division of Cardiovascular Medicine, Department of Medicine, Harrington Heart Vascular Institute, University Hospitals Case Medical Center, Cleveland, OH (I.T.C., J.A.M., J.S.); Division of Cardiovascular Medicine, University of Texas Medical Branch, Galveston (A.A.B.); and Virginia Mason Medical Center, Seattle, WA (R.W.R.)
| | - Robert W Rho
- From the Division of Cardiovascular Medicine, Section of Electrophysiology, University of Wisconsin, Madison (K.S.H.); Division of Cardiovascular Medicine, Section of Electrophysiology, University of California, San Francisco (B.K.L., V.V., M.M.S.); Division of Cardiovascular Medicine, Department of Medicine, Harrington Heart Vascular Institute, University Hospitals Case Medical Center, Cleveland, OH (I.T.C., J.A.M., J.S.); Division of Cardiovascular Medicine, University of Texas Medical Branch, Galveston (A.A.B.); and Virginia Mason Medical Center, Seattle, WA (R.W.R.)
| | - Melvin M Scheinman
- From the Division of Cardiovascular Medicine, Section of Electrophysiology, University of Wisconsin, Madison (K.S.H.); Division of Cardiovascular Medicine, Section of Electrophysiology, University of California, San Francisco (B.K.L., V.V., M.M.S.); Division of Cardiovascular Medicine, Department of Medicine, Harrington Heart Vascular Institute, University Hospitals Case Medical Center, Cleveland, OH (I.T.C., J.A.M., J.S.); Division of Cardiovascular Medicine, University of Texas Medical Branch, Galveston (A.A.B.); and Virginia Mason Medical Center, Seattle, WA (R.W.R.).
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MATÍA ROBERTO, HERNÁNDEZ-MADRID ANTONIO, SÁNCHEZ INMACULADA, LUMIA GIUSEPPE, FRANCO EDUARDO, ZAMORANO JOSÉLUIS, MORENO JAVIER. Narrow QRS Tachycardia in a Patient with Spongiform Cardiopathy and Preexcitation: What is the Mechanism? J Cardiovasc Electrophysiol 2014; 25:1408-10. [DOI: 10.1111/jce.12538] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2014] [Revised: 08/12/2014] [Accepted: 08/19/2014] [Indexed: 11/26/2022]
Affiliation(s)
- ROBERTO MATÍA
- Arrhythmia Unit; Cardiology Department; Hospital Ramón y Cajal; Madrid Spain
| | | | - INMACULADA SÁNCHEZ
- Arrhythmia Unit; Cardiology Department; Hospital Ramón y Cajal; Madrid Spain
| | - GIUSEPPE LUMIA
- Arrhythmia Unit; Cardiology Department; Hospital Ramón y Cajal; Madrid Spain
| | - EDUARDO FRANCO
- Arrhythmia Unit; Cardiology Department; Hospital Ramón y Cajal; Madrid Spain
| | - JOSÉ LUIS ZAMORANO
- Arrhythmia Unit; Cardiology Department; Hospital Ramón y Cajal; Madrid Spain
| | - JAVIER MORENO
- Arrhythmia Unit; Cardiology Department; Hospital Ramón y Cajal; Madrid Spain
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13
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A narrow complex tachycardia with intermittent atrioventricular dissociation: What is the mechanism? Heart Rhythm 2014; 11:2116-9. [DOI: 10.1016/j.hrthm.2014.06.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Indexed: 11/21/2022]
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14
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Pott C, Wegner FK, Bögeholz N, Frommeyer G, Dechering DG, Zellerhoff S, Kochhäuser S, Milberg P, Köbe J, Wasmer K, Mönnig G, Eckardt L. A patient series of dual atrioventricular nodal nonreentrant tachycardia (DAVNNT) — An often overlooked diagnosis? Int J Cardiol 2014; 172:e9-e11. [DOI: 10.1016/j.ijcard.2013.12.109] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Accepted: 12/20/2013] [Indexed: 10/25/2022]
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16
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Viswanathan MN, Scheinman M, Badhwar N. Narrow Complex Tachycardia: What is the Mechanism? Card Electrophysiol Clin 2010; 2:203-207. [PMID: 28770751 DOI: 10.1016/j.ccep.2010.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
This article reports an interesting case of a narrow complex tachycardia presenting the diagnostic dilemma of differentiating atrioventricular nodal reentrant tachycardia (AVNRT) from junctional tachycardia. It proposes delivering late-coupled premature atrial complexes during the tachycardia with short ventriculo-atrial interval as a diagnostic maneuver to differentiate AVNRT from junctional tachycardia in the electrophysiology laboratory. Treatments of these arrhythmias vary, and making the appropriate diagnosis of supraventricular tachycardia is essential to providing effective arrhythmia management.
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Affiliation(s)
- Mohan N Viswanathan
- Division of Cardiology, Section of Cardiac Electrophysiology, University of Washington School of Medicine, 1959 NE Pacific Street, Box 356422, Seattle, WA 98195-6422, USA
| | - Melvin Scheinman
- Division of Cardiology, Section of Cardiac Electrophysiology, University of California, 500 Parnassus Avenue, Box 1354, San Francisco, CA 94143-1354, USA
| | - Nitish Badhwar
- Division of Cardiology, Section of Cardiac Electrophysiology, University of California, 500 Parnassus Avenue, Box 1354, San Francisco, CA 94143-1354, USA
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17
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Affiliation(s)
- Frank C. Chen
- From the Department of Medicine (F.C.C., S.J.A.), Division of Cardiovascular Diseases, and Department of Pediatric and Adolescent Medicine (S.J.A.), Division of Pediatric Cardiology, Mayo Clinic, Rochester, Minn
| | - Samuel J. Asirvatham
- From the Department of Medicine (F.C.C., S.J.A.), Division of Cardiovascular Diseases, and Department of Pediatric and Adolescent Medicine (S.J.A.), Division of Pediatric Cardiology, Mayo Clinic, Rochester, Minn
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18
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Issa ZF. Mechanism of paroxysmal supraventricular tachycardia with ventriculoatrial conduction block. Europace 2009; 11:1235-7. [PMID: 19578175 DOI: 10.1093/europace/eup176] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Supraventricular tachycardia (SVT) with ventriculoatrial (VA) block. We report the case of a 25-year-old patient with paroxysmal SVT and intermittent VA block. Atrioventricular nodal re-entrant tachycardia with upper common pathway block and orthodromic nodoventricular or nodofascicular re-entrant tachycardia was considered in the differential diagnosis. Diagnostic characteristics were most compatible with non-re-entrant junctional tachycardia. The arrhythmia was cured by ablation at the right atrial posterior septum.
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Affiliation(s)
- Ziad F Issa
- Prairie Cardiovascular Consultants, Southern Illinois University, 401 East Carpenter Street, Springfield, IL 62702, USA.
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19
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Morihisa K, Yamabe H, Uemura T, Tanaka Y, Enomoto K, Kawano H, Nagayoshi Y, Kaikita K, Sumida H, Sugiyama S, Ogawa H. Analysis of atrioventricular nodal reentrant tachycardia with variable ventriculoatrial block: characteristics of the upper common pathway. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2009; 32:484-93. [PMID: 19335858 DOI: 10.1111/j.1540-8159.2009.02309.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND The precise nature of the upper turnaround part of atrioventricular nodal reentrant tachycardia (AVNRT) is not entirely understood. METHODS In nine patients with AVNRT accompanied by variable ventriculoatrial (VA) conduction block, we examined the electrophysiologic characteristics of its upper common pathway. RESULTS Tachycardia was induced by atrial burst and/or extrastimulus followed by atrial-His jump, and the earliest atrial electrogram was observed at the His bundle site in all patients. Twelve incidents of VA block: Wenckebach VA block (n = 7), 2:1 VA block (n = 4), and intermittent (n = 1) were observed. In two of seven Wenckebach VA block, the retrograde earliest atrial activation site shifted from the His bundle site to coronary sinus ostium just before VA block. Prolongation of His-His interval occurred during VA block in 11 of 12 incidents. After isoproterenol administration, 1:1 VA conduction resumed in all patients. Catheter ablation at the right inferoparaseptum eliminated antegrade slow pathway conduction and rendered AVNRT noninducible in all patients. CONCLUSION Selective elimination of the slow pathway conduction at the inferoparaseptal right atrium may suggest that the subatrial tissue linking the retrograde fast and antegrade slow pathways forms the upper common pathway in AVNRT with VA block.
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Affiliation(s)
- Kenji Morihisa
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
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Balasundaram R, Rao HB, Kalavakolanu S, Narasimhan C. Catheter ablation of bundle branch reentrant ventricular tachycardia. Heart Rhythm 2008; 5:S68-72. [DOI: 10.1016/j.hrthm.2008.02.036] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2008] [Indexed: 11/27/2022]
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21
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LAU ERNESTW. Infraatrial Supraventricular Tachycardias: Mechanisms, Diagnosis, and Management. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2008; 31:490-8. [DOI: 10.1111/j.1540-8159.2008.01020.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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22
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KATRITSIS DEMOSTHENESG. Upper and Lower Common Pathways in Atrioventricular Nodal Reentrant Tachycardia:. Refutation of a Legend? PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2007; 30:1305-8. [DOI: 10.1111/j.1540-8159.2007.00861.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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23
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Palanca V, Quesada A, Jimenez J, Jacas V. Wide QRS tachycardia with ventriculoatrial dissociation in early postoperative aortic valve replacement period: an atypical nodal reentry presentation. Cardiology 2007; 109:68-72. [PMID: 17627112 DOI: 10.1159/000105329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2006] [Accepted: 10/27/2006] [Indexed: 11/19/2022]
Abstract
We report an atypical presentation of atrioventricular (AV) nodal reentry tachycardia with periods of ventriculoatrial Wenckebach and complete ventriculoatrial dissociation which appeared in a male patient in the postoperative period following aortic valve replacement and plication of Valsalva's posterior sinus. The context for the onset of this AV nodal reentry tachycardia and the concurrent electrophysiological findings support the hypothesis of a strictly nodal location of the circuit and suggest that the electrical modifications sustained by the perinodal region are the triggering agent for the reentry mechanism. Therefore, the AV nodal reentry is a mechanism that must be considered when tachycardia appears in the early postoperative period following aortic valve replacement.
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Affiliation(s)
- Victor Palanca
- Arrhythmia and Cardiac Pacing Unit, Cardiology Service, Consorcio Hospital General Universitario, Valencia, Spain.
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Ajiki K, Hayami N, Kasaoka Y, Imai Y, Fujiu K, Murakawa Y. Supraventricular Tachycardia Originating From the Posterior Atrioventricular Node in the Univentricular Heart With Single Atrium. Int Heart J 2007; 48:253-9. [PMID: 17409590 DOI: 10.1536/ihj.48.253] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Supraventricular tachycardia (SVT) was observed in a 13-year-old male patient with complex clinical features that included univentricular heart with single atrium, pulmonary atresia, and polysplenia syndrome. During electrophysiologic study, atrial burst stimuli reproducibly induced and terminated the SVT, while the occurrence of ventriculoatrial block did not interrupt the SVT. His bundle electrograms (HBEs) were recognized both in the anterior and posterior regions on the common atrioventricular (AV) valve annulus. The posterior His bundle activation was progressively delayed along with the shortening of atrial pacing cycle length until it finally lagged behind local ventricular activation. Thus, antegrade AV conduction was solely via the anterior AV node. In contrast, during the SVT, the earliest activation was observed in the posterior HBE. These observations suggested that the posterior AV node serves as an origin of the SVT and that two AV nodes were linked together possibly through a sling at the infra-Hisian level. Radiofrequency catheter ablation applied to the posterior HBE eliminated the SVT.
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Affiliation(s)
- Kohsuke Ajiki
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Japan
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25
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Sarkozy A, Boussy T, Chierchia GB, Geelen P, Brugada P. An Unusual Form of Bundle Branch Reentrant Tachycardia. J Cardiovasc Electrophysiol 2006; 17:902-6. [PMID: 16903970 DOI: 10.1111/j.1540-8167.2006.00468.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION We report the case of a 36-year-old patient with a longstanding history of paroxysmal tachycardia. METHODS AND RESULTS During the electrophysiological study, the H-V interval was prolonged in sinus rhythm, and a second potential (H'') with distal to proximal activation pattern was recorded in the region of the proximal His-Purkinje system. Two wide QRS complex tachycardias were induced, both with V-A dissociation. One application of radiofrequency energy at the site with earliest and largest H'' potential during sinus rhythm cured both tachycardias. The right and left bundle branch block morphology tachycardias were diagnosed as clockwise and counterclockwise bundle branch reentrant tachycardia. The H'' potential represented the retrograde right bundle potential during sinus rhythm and bundle branch block reentrant tachycardia.
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Affiliation(s)
- Andrea Sarkozy
- Cardiovascular Research and Teaching Institute Aalst, Cardiovascular Center, OLV Hospital, Moorselbaan, Aalst, Belgium.
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26
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Otomo K, Okamura H, Noda T, Satomi K, Shimizu W, Suyama K, Kurita T, Aihara N, Kamakura S. Unique electrophysiologic characteristics of atrioventricular nodal reentrant tachycardia with different ventriculoatrial block patterns: effects of slow pathway ablation and insights into the location of the reentrant circuit. Heart Rhythm 2006; 3:544-54. [PMID: 16648059 DOI: 10.1016/j.hrthm.2006.01.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2005] [Accepted: 01/20/2006] [Indexed: 10/25/2022]
Abstract
BACKGROUND The electrophysiologic mechanisms of different ventriculoatrial (VA) block patterns during atrioventricular nodal reentrant tachycardia (AVNRT) are poorly understood. OBJECTIVES The purpose of this study was to characterize AVNRTs with different VA block patterns and to assess the effects of slow pathway ablation. METHODS Electrophysiologic data from six AVNRT patients with different VA block patterns were reviewed. RESULTS All AVNRTs were induced after a sudden AH "jump-up" with the earliest retrograde atrial activation at the right superoparaseptum. Different VA block patterns comprised Wenckebach His-atrial (HA) block (n = 4), 2:1 HA block (n = 1), and variable HA conduction times during fixed AVNRT cycle length (CL) (n = 1). Wenckebach HA block during AVNRT was preceded by gradual HA interval prolongation with fixed His-His (HH) interval and unchanged atrial activation sequence. AVNRT with 2:1 HA block was induced after slow pathway ablation for slow-slow AVNRT with 1:1 HA conduction, and earliest atrial activation shifted from right inferoparaseptum to superoparaseptum without change in AVNRT CL. The presence of a lower common pathway was suggested by a longer HA interval during ventricular pacing at AVNRT CL than during AVNRT (n = 5) or Wenckebach HA block during ventricular pacing at AVNRT CL (n = 1). In four patients, HA interval during ventricular pacing at AVNRT CL was unusually long (188 +/- 30 ms). Ablations at the right inferoparaseptum rendered AVNRT noninducible in 5 (83%) of 6 patients. CONCLUSION Most AVNRTs with different VA block patterns were amenable to classic slow pathway ablation. The reentrant circuit could be contained within a functionally protected region around the AV node and posterior nodal extensions, and different VA block patterns resulted from variable conduction at tissues extrinsic to the reentrant circuit.
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Affiliation(s)
- Kiyoshi Otomo
- Division of Cardiology, National Cardiovascular Center, Suita, Japan.
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Abstract
Though patients with AV nodal reentry are now routinely cured by catheter ablation, the basic mechanism of this disorder is still under debate. The putative mechanism of AV node reentry was first discovered by the elegant work of Gordon Moe. He demonstrated the existence of dual pathways and echo beats in rabbits. Building on these seminal observations, the mechanism of AVNRT has burgeoned to include the possibility of left atrial input into the node. The first curative nonpharmacologic procedures involved surgical dissection around the AV node and the procedure was rapidly supplanted by catheter ablation procedures. The initial ablative procedure targeted the fast pathway, but later observations showed that ablation of the slow pathway was more effective and safer. Cure of AV nodal reentry which is the most common cause of paroxysmal supraventricular tachycardia became possible through the cooperative efforts of anatomists, physiologists, surgeons, and clinical electrophysiologists.
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Chugh A, Elmouchi D, Han J. Termination of tachycardia with a ventricular extrastimulus: What is the mechanism? Heart Rhythm 2005; 2:1148-9. [PMID: 16188599 DOI: 10.1016/j.hrthm.2005.04.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2005] [Indexed: 10/25/2022]
Affiliation(s)
- Aman Chugh
- Division of Cardiology, University of Michigan Hospitals, Ann Arbor, Michigan 48109-0311, USA.
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Cao K, Chen M, Zou J, Shan Q, Chen C, Yang B, Zhu L, Xu D, Jin Y, Gonska BD. Narrow QRS Tachycardia with Ventriculoatrial Dissociation Mediated by a Left Fasciculoventricular Fiber. J Interv Card Electrophysiol 2005; 13:151-7. [PMID: 16133843 DOI: 10.1007/s10840-005-0204-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2004] [Accepted: 04/12/2005] [Indexed: 10/25/2022]
Abstract
A 30-year-old man presented with narrow QRS tachycardia. The intracardiac electrocardiogram showed an atrial-HIS (AH) interval of 75 msec and a HIS-ventricular (HV) interval of 44 msec during baseline. Atrial incremental pacing revealed HV shortening, with apparent incomplete right bundle branch block (RBBB) morphology without QRS complex axis deviation. The induced tachycardia exhibited several QRS morphologies: a narrow QRS, complete RBBB and complete left bundle branch block (LBBB) morphology. Spontaneous conversion of the QRS pattern from wide to narrow was observed. The cycle length of the tachycardia was significantly shortened (from 316 to 272 ms) from LBBB morphology to narrow QRS complex. The atrial activation was dissociated from the ventricular activation during all tachycardias. Each QRS complex during tachycardia was preceded by a HIS deflection and HV interval was 35 ms, which was shorter than that of sinus rhythm. HIS deflection was earlier than right bundle potential during all kinds of tachycardia. This tachycardia is most likely mediated by a left fasciculoventricular fiber which connects the HIS bundle below the atrioventricular node to the myocardial tissue of the left ventricle. The HIS-Purkinje system is used as an antegrade conduction limb and the fasciculoventricular fiber as a retrograde limb in the tachycardia circuit.
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Affiliation(s)
- Kejiang Cao
- Department of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, People's Republic of China
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30
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Huang BH, Liu TY, Chen SA. A Narrow Complex Tachycardia with Ventriculoatrial Dissociation After Catheter Ablation of Atrioventricular Nodal Reentrant Tachycardia:. What is the Mechanism? Pacing Clin Electrophysiol 2004; 27:101-3. [PMID: 14720164 DOI: 10.1111/j.1540-8159.2004.00394.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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31
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Kirchhof P, Loh P, Ribbing M, Wasmer K. Incessant supraventricular tachycardia with constant 1:2 atrioventricular ratio: a longitudinally dissociated atrioventricular node? J Cardiovasc Electrophysiol 2003; 14:316-9. [PMID: 12716118 DOI: 10.1046/j.1540-8167.2003.02378.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We report a patient with incessant, exercise-limiting supraventricular tachycardia on the ventricular level and a constant 1:2 atrioventricular relation. Careful mapping of the AV nodal region revealed His alternans in the inferior AV nodal area and nonalternating His morphologies in the superior His region. Radiofrequency catheter ablation in the inferior AV node cured the patient (11-month follow-up). Constant dual ventricular activation, His alternans, distinct His morphologies in the superior and inferior His, and long-term suppression of the tachycardia by ablation in the so-called slow pathway region of the AV node are suggestive of permanent dual anterograde AV nodal conduction in this patient.
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Affiliation(s)
- Paulus Kirchhof
- Department of Cardiology and Angiology, University Hospital Münster, Münster, Germany.
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32
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Strohmer B, Schernthaner C, Pichler M. Paroxysmal supraventricular tachycardia with persistent ventriculoatrial block. J Cardiovasc Electrophysiol 2003; 14:90-3. [PMID: 12625618 DOI: 10.1046/j.1540-8167.2003.02402.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We report the case of a 64-year-old patient with paroxysmal supraventricular tachycardia and persistent VA block. Induction and maintenance of tachycardia occurred without apparent activation of the atria. Diagnostic characteristics were most compatible with AV nodal reentrant tachycardia (AVNRT). Automatic junctional tachycardia and orthodromic nodoventricular or nodofascicular reentry tachycardia were considered in the differential diagnosis. Upper common pathway block during AVNRT may be explained by either intra-atrial conduction block or purely intranodal confined AVNRT. The arrhythmia was cured by a typical posteroseptal ablation approach guided by slow pathway potentials.
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MESH Headings
- Cardiac Pacing, Artificial
- Catheter Ablation
- Diagnosis, Differential
- Electrocardiography, Ambulatory
- Electrophysiologic Techniques, Cardiac
- Female
- Heart Block/diagnosis
- Heart Block/physiopathology
- Heart Block/therapy
- Heart Conduction System/physiopathology
- Heart Conduction System/surgery
- Humans
- Middle Aged
- Recurrence
- Tachycardia, Paroxysmal/diagnosis
- Tachycardia, Paroxysmal/physiopathology
- Tachycardia, Paroxysmal/therapy
- Tachycardia, Supraventricular/diagnosis
- Tachycardia, Supraventricular/physiopathology
- Tachycardia, Supraventricular/therapy
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Affiliation(s)
- Bernhard Strohmer
- Department of Cardiology, Landeskliniken Salzburg, Salzburg, Austria.
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Merino JL, Peinado R, Fernandez-Lozano I, Lopez-Gil M, Arribas F, Ramirez LJ, Echeverria IJ, Sobrino JA. Bundle-branch reentry and the postpacing interval after entrainment by right ventricular apex stimulation: a new approach to elucidate the mechanism of wide-QRS-complex tachycardia with atrioventricular dissociation. Circulation 2001; 103:1102-8. [PMID: 11222473 DOI: 10.1161/01.cir.103.8.1102] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Diagnosis of bundle-branch reentry ventricular tachycardia (BBR-VT) by the standard approach is challenging, and this may lead to nonrecognition of this tachycardia mechanism. Because the postpacing interval (PPI) after entrainment has been correlated with the distance from the pacing site to the reentrant circuit, BBR-VT entrainment by pacing from the right ventricular apex (RVA) should result in a PPI similar to the tachycardia cycle length (TCL). This factor may differentiate BBR-VT from other mechanisms of wide-QRS-complex tachycardia with AV dissociation, such as myocardial reentrant VT (MR-VT) or AV nodal reentrant tachycardia (AVNRT), in which the circuit is usually located away from the RVA. METHODS AND RESULTS Transient entrainment by RVA pacing was attempted in 18 consecutive BBR-VTs and finally achieved in 13. Results were compared with those found in 59 consecutive MR-VTs and 50 consecutive AVNRTs. The mean PPI-TCL difference was significantly (P:<0.0001) shorter in the BBR-VT group (9+/-11 ms) than in the MR-VT (109+/-48 ms) and the AVNRT (150+/-29 ms) groups. No BBR-VT showed a PPI-TCL >30 ms (range -12 to 24 ms). Except for 2 MR-VTs, no MR-VT (range 21 to 211 ms) or AVNRT (range 100 to 215 ms) showed a PPI-TCL <30 ms. CONCLUSIONS A PPI-TCL >30 ms, after entrainment by RVA stimulation, makes BBR-VT unlikely. Conversely, a PPI-TCL <30 ms is suggestive of BBR-VT but should lead to further investigation by use of conventional criteria.
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Affiliation(s)
- J L Merino
- Arrhythmia and Electrophysiology Unit, UMQ de Cardiología, Hospital La Paz, Universidad Autónoma, Madrid, Spain.
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Hluchy J, Schickel S, Jörger U, Jurkovicova O, Sabin GV. Electrophysiologic characteristics and radiofrequency ablation of concealed nodofascicular and left anterograde atriofascicular pathways. J Cardiovasc Electrophysiol 2000; 11:211-7. [PMID: 10709718 DOI: 10.1111/j.1540-8167.2000.tb00323.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION True nodoventricular or nodofascicular pathways and left-sided anterograde decremental accessory pathways (APs) are considered rare findings. METHODS AND RESULTS Two unusual patients with paroxysmal supraventricular tachycardia were referred for radiofrequency (RF) ablation. Both patients had evidence of dual AV nodal conduction. In case 1, programmed atrial and ventricular stimulation induced regular tachycardia with a narrow QRS complex or episodes of right and left bundle branch block not altering the tachycardia cycle length and long concentric ventriculoatrial (VA) conduction. Ventricular extrastimuli elicited during His-bundle refractoriness resulted in tachycardia termination. During the tachycardia, both the ventricles and the distal right bundle were not part of the reentrant circuit. These findings were consistent with a concealed nodofascicular pathway. RF ablation in the right atrial mid-septal region with the earliest atrial activation preceded by a possible AP potential resulted in tachycardia termination and elimination of VA conduction. In case 2, antidromic reciprocating tachycardia of a right bundle branch block pattern was considered to involve an anterograde left posteroseptal atriofascicular pathway. For this pathway, decremental conduction properties as typically observed for right atriofascicular pathways could be demonstrated. During atrial stimulation and tachycardia, a discrete AP potential was recorded at the atrial and ventricular insertion sites and along the AP. Mechanical conduction block of the AP was reproducibly induced at the annular level and at the distal insertion site. Successful RF ablation was performed at the mitral annulus. CONCLUSION This report describes two unusual cases consistent with concealed nodofascicular and left anterograde atriofascicular pathways, which were ablated successfully without impairing normal AV conduction system.
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Affiliation(s)
- J Hluchy
- Department of Cardiology and Angiology, Elisabeth Hospital, Essen, Germany
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Merino JL, Peinado R, Fernández-Lozano I, Sobrino N, Sobrino JA. Transient entrainment of bundle-branch reentry by atrial and ventricular stimulation: elucidation of the tachycardia mechanism through analysis of the surface ECG. Circulation 1999; 100:1784-90. [PMID: 10534465 DOI: 10.1161/01.cir.100.17.1784] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Different responses to entrainment have been reported in relation to the pacing site of a variety of tachycardias. However, transient entrainment of bundle-branch reentrant tachycardia (BBRT) has not been investigated systematically. METHODS AND RESULTS We attempted entrainment of 13 BBRTs in 9 patients by pacing first the right ventricle and then the right atrium. The initial pacing cycle length (CL) was 10 ms faster than the tachycardia CL. Subsequent pacing sequences were performed with 5- to 10-ms CL decrements until tachycardia termination or loss of postatropine 1:1 AV conduction. Both full ventricular-paced and AV-conducted QRS complex references were obtained during sinus rhythm pacing from the same sites and with similar CL as during entrainment. Transient entrainment was achieved by ventricular and atrial stimulation in 11 and 8 tachycardias, respectively. Constant fusion was always present during entrainment by ventricular stimulation. There was no change in the QRS complex (orthodromically concealed fusion) during entrainment by atrial stimulation in 6 of 6 tachycardias with left bundle-branch block morphology and in 1 of 2 tachycardias with right bundle-branch block morphology. CONCLUSIONS BBRT, especially if it has a left bundle-branch block morphology, can be differentiated from other wide-QRS-complex tachycardia mechanisms through analysis of the ECGs recorded during tachycardia entrainment by atrial and ventricular stimulation. This diagnostic approach may be especially useful when it is difficult to record a stable or sufficiently sized His bundle electrogram or when spontaneous changes in the ventricular CL precede similar changes in the His bundle CL.
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Affiliation(s)
- J L Merino
- Arrhythmia Unit, Department of Cardiology, Hospital La Paz, Universidad Autónoma, Madrid, Spain.
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36
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Trohman RG, Haery C, Pinski SL. Focal radiofrequency catheter ablation of an irregularly irregular supraventricular tachycardia. Pacing Clin Electrophysiol 1999; 22:360-2. [PMID: 10087552 DOI: 10.1111/j.1540-8159.1999.tb00450.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- R G Trohman
- Section of Cardiology, Rush-Presbyterian-St. Luke's Medical Center and Rush Medical College, Chicago, Illinois
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