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Warren PW, Powell AW, Knilans T, Connor C, Baskar S. Double Ventricular Response with Aberrant Conduction Leading to Ventricular Dysfunction. Pediatr Cardiol 2024:10.1007/s00246-024-03506-9. [PMID: 38709261 DOI: 10.1007/s00246-024-03506-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 04/22/2024] [Indexed: 05/07/2024]
Abstract
Double ventricular response (DVR), where a single P wave results in two QRS complexes, is a rare presentation of dual AV node physiology. It has been associated with ventricular dysfunction in the setting of incessant tachycardia. We present the case of an otherwise healthy adolescent who had frequent DVR without tachycardia leading to left ventricular dysfunction. Slow pathway modification led to a significant reduction in ectopy and normalization of ventricular function. This highlights that DVR without tachycardia might lead to ventricular dysfunction in pediatric patients. Slow pathway modification with reduction of ectopy may be sufficient to restore ventricular function.
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Affiliation(s)
- Paul W Warren
- The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnett Ave., MLC 2003, Cincinnati, OH, 45229-3026, USA
| | - Adam W Powell
- The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnett Ave., MLC 2003, Cincinnati, OH, 45229-3026, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Timothy Knilans
- The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnett Ave., MLC 2003, Cincinnati, OH, 45229-3026, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Chad Connor
- The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnett Ave., MLC 2003, Cincinnati, OH, 45229-3026, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Shankar Baskar
- The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnett Ave., MLC 2003, Cincinnati, OH, 45229-3026, USA.
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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Penfold MP, Cannon BC, Wackel PL. Empiric Slow Pathway Cryoablation in Symptomatic Children Without Documented Supraventricular Tachycardia. Pediatr Cardiol 2024; 45:921-925. [PMID: 36462026 DOI: 10.1007/s00246-022-03065-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 11/22/2022] [Indexed: 12/05/2022]
Abstract
In symptomatic children without documented supraventricular tachycardia (SVT) and non-inducible atrioventricular nodal reentry tachycardia (AVNRT) the benefit of empiric slow pathway (SP) ablation is unknown. We evaluated 62 symptomatic patients without documented SVT that underwent electrophysiology study (EPS). The purpose of this study was to determine if symptoms improved after empiric SP ablation in children without documented SVT and without inducible AVNRT. Sixty-two symptomatic patients without previously documented SVT underwent EPS; 31 (50%) had inducible AVNRT and underwent SP ablation, 20 (32%) were non-inducible and underwent empiric SP ablation, 11 (18%) were non-inducible and had no ablation. After a mean follow-up of 23 ± 18 months there was no significant difference in freedom from symptoms within the non-inducible cohort regardless of whether empiric SP ablation was performed (p = 0.135). There was a significant improvement in symptoms at follow-up after SP ablation when comparing inducible and non-inducible patients (p = 0.020). During follow-up no patients had documented SVT. Symptomatic children without documented SVT do not benefit from empiric SP ablation when AVNRT cannot be induced.
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Affiliation(s)
- Michael P Penfold
- Department of Pediatrics, Mayo Clinic, Rochester, MN, 200 1st SW55901, USA.
| | - Bryan C Cannon
- Division of Pediatric Cardiology, Mayo Clinic, Rochester, MN, 200 1 st SW55901, USA
| | - Philip L Wackel
- Division of Pediatric Cardiology, Mayo Clinic, Rochester, MN, 200 1 st SW55901, USA
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Telishevska M, Lengauer S, Reents T, Kantenwein V, Popa M, Bahlke F, Englert F, Erhard N, Deisenhofer I, Hessling G. Long-Term Follow-Up of Empirical Slow Pathway Ablation in Pediatric and Adult Patients with Suspected AV Nodal Reentrant Tachycardia. J Clin Med 2023; 12:6532. [PMID: 37892670 PMCID: PMC10607303 DOI: 10.3390/jcm12206532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 10/04/2023] [Accepted: 10/11/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND The aim of this study was to assess long-term efficacy and safety of empirical slow pathway (ESP) ablation in pediatric and adult patients with a special interest in patients without dual AV nodal physiology (DAVNP). METHODS A retrospective single-center review of patients who underwent ESP ablation between December 2014 and September 2022 was performed. Follow-up included telephone communication, letter questionnaire and outpatient presentation. Recurrence was based on typical symptoms. RESULTS 115 patients aged 6-81 years (median age 36.3 years, 59.1% female; 26 pts < 18 years) were included. A typical history was present in all patients (100%), an ECG documentation of narrow complex tachycardia in 97 patients (84%). Patients were divided into three groups: Group 1 without DAVNP (n = 23), Group 2 with AH jump (n = 30) and Group 3 with AH jump and at least one AV nodal echo beat (n = 62). No permanent AV block was observed. During a median follow-up of 23.6 ± 22.7 months, symptom recurrence occurred in 7/115 patients (6.1%) with no significant difference between the groups (p = 0.73, log-rank test). Symptom recurrence occurred significantly more often in patients without (5/18 patients; 27%) as compared to patients with ECG documentation (2/97 patients; 2.1%; p = 0.025). No correlation between age and success rate was found (p > 0.1). CONCLUSIONS ESP ablation is effective and safe in patients with non-inducible AVNRT. Overall, recurrence of symptoms during long-term follow-up is low, even if no DAVNP is present. Tachycardia documentation before the EP study leads to a significantly lower recurrence rate following ESP ablation.
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Affiliation(s)
- Marta Telishevska
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich, Lazarettstr. 36, 80636 Munich, Germany; (S.L.); (T.R.); (V.K.); (M.P.); (F.B.); (F.E.); (N.E.); (I.D.); (G.H.)
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Abstract
There is minimal data regarding antegrade-only accessory pathways in young patients. Given evolving recommendations and treatments, retrospective analysis of the clinical and electrophysiologic properties of antegrade-only pathways in patients <21 years old was performed, with subsequent comparison of electrophysiology properties to age-matched controls with bidirectional pathways. Of 522 consecutive young patients with ventricular pre-excitation referred for electrophysiology study, 33 (6.3%) had antegrade-only accessory pathways. Indications included palpitations (47%), chest pain (25%), and syncope (22%). The shortest value for either the accessory pathway effective refractory period or the pre-excited R-R interval was taken for each patient, with the median of the antegrade-only group significantly greater than shortest values for the bidirectional group (310 [280-360] ms versus 270 [240-302] ms, p < 0.001). However, the prevalence of pathways with high-risk properties (effective refractory period or shortest pre-excited R-R interval <250 ms) was similar in both study patients and controls (13% versus 21%) (p = 0.55). Sixteen patients had a single antegrade-only accessory pathway and no inducible arrhythmia. Six patients had Mahaim fibres, all right anterolateral with inducible antidromic reciprocating tachycardia. However, 11 patients with antegrade-only accessory pathways and 3 with Mahaim fibres had inducible tachycardia due to a second substrate recognised at electrophysiology study. These included concealed accessory pathways (7), bidirectional accessory pathways (5), and atrioventricular node re-entry (2). Antegrade-only accessory pathways require comprehensive electrophysiology evaluation as confounding factors such as high-risk conduction properties or inducible Supraventricular Tachycardia (SVT) due to a second substrate of tachycardia are often present.
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Duman D, Ertuğrul İ, Yıldırım Baştuhan I, Aykan HH, Karagöz T. Empiric slow-pathway ablation results for presumed atrioventricular nodal reentrant tachycardia in pediatric patients. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 44:1200-1206. [PMID: 34080209 DOI: 10.1111/pace.14291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 03/29/2021] [Accepted: 05/16/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND In pediatric patients with documented narrow QRS tachycardia that is suggestive of atrioventricular nodal reentrant tachycardia (AVNRT) and not inducible in electrophysiological study (EPS), empiric slowpathway ablation (ESPA) may be considered. There is limited data in children about this topic. METHODS Seventy-nine patients who underwent cryoablation and/or radiofrequency ablation (RFA) for presumed AVNRT between January 2010 and January 2020, with no inducible tachycardia and no other tachycardia mechanisms during EPS, were included in this study. RESULTS The age was between 6 and 18 years. All patients had no structural heart disease. Preablation exhibited sustained SP conduction for all patients. In all cases, the ablation end points were prolongation in wenckebach cycle length (WBCL) with loss of cross and/or jump, and/or echo beat. The end points were not achieved in two patients. Overall, the mean basal WBCL increased to 351 ms (240-500 ms) from 301.3 ms (180-420 ms), evident in the non-recurrence group. Nine patients had a transient AV block that improved. We followed the patients without medication for about 46.9 months (8 months to 10 years). Palpitations occurred again in 9 of 77 patients (clinical recurrence rate 9/79 - 11.3%). The documented ECG recurrence rate was 1.2% (1/79). In the non-recurrence group, WBCL prolongation was higher and mean age was lower than in the recurrence group (13.075 vs. 15.33 years). CONCLUSION In cases with presumed AVNRT, ESPA seems to be a reasonable and safe way. In our study, we found our procedural success rate as 97.4% and follow-up recurrence rate as 12.6% (9+1/79).
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Affiliation(s)
- Derya Duman
- Department of Pediatrics, Division of Pediatric Cardiology, University of Hacettepe, Ankara, Turkey
| | - İlker Ertuğrul
- Department of Pediatrics, Division of Pediatric Cardiology, University of Hacettepe, Ankara, Turkey
| | - Işıl Yıldırım Baştuhan
- Division of Pediatric Cardiology, University of Health Sciences Antalya Training and Research Hospital, Antalya, Dalian
| | - Hayrettin Hakan Aykan
- Department of Pediatrics, Division of Pediatric Cardiology, University of Hacettepe, Ankara, Turkey
| | - Tevfik Karagöz
- Department of Pediatrics, University of Hacettepe, Ankara, Turkey
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Dasgupta S, Kelleman M, Whitehill R, Fischbach P. Recurrent single echo beats after cryoablation of atrioventricular nodal reentrant tachycardia: The pediatric population. Indian Pacing Electrophysiol J 2020; 20:173-177. [PMID: 32311435 PMCID: PMC7517539 DOI: 10.1016/j.ipej.2020.04.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 04/08/2020] [Accepted: 04/11/2020] [Indexed: 10/29/2022] Open
Abstract
BACKGROUND Cryoablation for atrioventricular nodal reentrant tachycardia (AVNRT) is effective and safe with a reported limitation of lower success and higher recurrence rates. We have observed cases in which slow pathway conduction was eliminated as demonstrated by atrial extra-stimulus testing within 1 min of cryo-energy delivery but returned following tissue rewarming. Frequently, slow pathway conduction persisted despite multiple acutely successful lesions over a broad anatomic region. We aimed to determine if return of slow pathway conduction after elimination during cryoablation represents a risk for recurrent AVNRT with the same intermediate term results as slow pathway ablation. We hypothesize that remnant single echo beats in the absence of sustained slow pathway conduction and inducible AVNRT is an acceptable end point after clear slow pathway elimination during cryoablation. METHODS Retrospective chart review of patients undergoing attempted slow pathway ablation for AVNRT using solely cryoablation between January 2015-January 2018. RESULTS Forty-four patients met inclusion criteria with at-least 2 features of dual AVN physiology. 19 patients had return of slow pathway conduction shortly after clear elimination during cryoablation (Group A) while 25 did not (Group B). All in Group A had recurrent single echo beats but none had sustained slow pathway conduction at the end of the procedure nor AVNRT recurrence at 1 year. CONCLUSION Recurrent single echo beats with absent sustained slow pathway conduction and non-inducible AVNRT may be an acceptable endpoint for slow pathway ablation of AVNRT using cryoablation when there is elimination of slow pathway demonstrated during energy delivery.
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Affiliation(s)
- Soham Dasgupta
- Division of Pediatric Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Atlanta, GA, USA.
| | | | - Robert Whitehill
- Division of Pediatric Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Peter Fischbach
- Division of Pediatric Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Atlanta, GA, USA
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Lee PJ, Varosy P, Sandhu A. Uncommon presentation of a common disorder: Syncope with AVNRT in setting of a structural anomaly. Clin Case Rep 2020; 8:477-480. [PMID: 32185039 PMCID: PMC7069882 DOI: 10.1002/ccr3.2674] [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: 08/19/2019] [Revised: 11/18/2019] [Accepted: 12/12/2019] [Indexed: 12/02/2022] Open
Abstract
Syncope in setting of AV nodal re-entrant tachycardia should prompt the clinician to perform further workup for comorbid conditions, including structural cardiac abnormalities. In complex cases, ICE may be helpful in delineating the anatomy to facilitate safe ablations.
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Affiliation(s)
| | - Paul Varosy
- Section of ElectrophysiologyDivision of CardiologyUniversity of ColoradoAuroraColorado
- Section of CardiologyEastern Colorado VA Medical CenterAuroraColorado
| | - Amneet Sandhu
- Section of ElectrophysiologyDivision of CardiologyUniversity of ColoradoAuroraColorado
- Section of CardiologyEastern Colorado VA Medical CenterAuroraColorado
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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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Clark BC, Berul CI. Arrhythmia diagnosis and management throughout life in congenital heart disease. Expert Rev Cardiovasc Ther 2016; 14:301-20. [PMID: 26642231 DOI: 10.1586/14779072.2016.1128826] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Arrhythmias, covering bradycardia and tachycardia, occur in association with congenital heart disease (CHD) and as a consequence of surgical repair. Symptomatic bradycardia can occur due to sinus node dysfunction or atrioventricular block secondary to either unrepaired CHD or surgical repair in the area of the conduction system. Tachyarrhythmias are common in repaired CHD due to scar formation, chamber distension or increased chamber pressure, all potentially leading to abnormal automaticity and heterogeneous conduction properties as a substrate for re-entry. Atrial arrhythmias occur more frequently, but ventricular tachyarrhythmias may be associated with an increased risk of sudden cardiac death, notably in patients with repaired tetralogy of Fallot or aortic stenosis. Defibrillator implantation provides life-saving electrical therapy for hemodynamically unstable arrhythmias. Ablation procedures with 3D electroanatomic mapping technology offer a viable alternative to pharmacologic or device therapy. Advances in electrophysiology have allowed for successful management of arrhythmias in patients with congenital heart disease.
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Affiliation(s)
- Bradley C Clark
- a Division of Cardiology , Children's National Health System , Washington , DC , USA.,b Department of Pediatrics , George Washington University School of Medicine , Washington , DC , USA
| | - Charles I Berul
- a Division of Cardiology , Children's National Health System , Washington , DC , USA.,b Department of Pediatrics , George Washington University School of Medicine , Washington , DC , USA
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REDDY CHARITHAD, SILKA MICHAELJ, BAR-COHEN YANIV. A Comparison of AV Nodal Reentrant Tachycardia in Young Children and Adolescents: Electrophysiology, Ablation, and Outcomes. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2015; 38:1325-32. [DOI: 10.1111/pace.12699] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Revised: 06/15/2015] [Accepted: 07/15/2015] [Indexed: 11/28/2022]
Affiliation(s)
- CHARITHA D. REDDY
- Department of Pediatrics; Children's Hospital Los Angeles; Los Angeles California
| | - MICHAEL J. SILKA
- Division of Cardiology, Children's Hospital Los Angeles, Los Angeles, California; and Keck School of Medicine; University of Southern California; Los Angeles California
| | - YANIV BAR-COHEN
- Division of Cardiology, Children's Hospital Los Angeles, Los Angeles, California; and Keck School of Medicine; University of Southern California; Los Angeles California
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Leila R, Raluca P, Yves DG, Dirk S, Bruno S. Cryoablation Versus Radiofrequency Ablation in AVNRT: Same Goal, Different Strategy. J Atr Fibrillation 2015; 8:1220. [PMID: 27957174 DOI: 10.4022/jafib.1220] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Revised: 05/07/2015] [Accepted: 05/11/2015] [Indexed: 11/10/2022]
Abstract
Catheter ablation is nowadays the first therapeutic option for AVNRT, the most common benign supraventricular tachycardia. Both cryotherapy and radiofrequency energy may be used to ablate the slow pathway. This paper compares both techniques, evaluates results published in literature and gives feedback on some typical aspects of cryo- and RF ablation. Although both techniques have satisfying success rates in AVNRT ablation, with a higher safety profile of cryoablation towards creation of inadvertent atrioventricular block, it remains paramount that the operator respects the distinctive traits of each technique in order to obtain an optimal result in every patient.
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Affiliation(s)
- Yuji Murakawa
- Fourth Department of Internal Medicine, Teikyo University School of Medicine
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