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Ren B, Cao Y, Li J, Li F, Wang C, Xiao M, Hu X, Zeng R. The impact of His bundle location and direction on the efficacy and safety of ablation. Pacing Clin Electrophysiol 2024. [PMID: 39132936 DOI: 10.1111/pace.15053] [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: 04/14/2024] [Revised: 06/05/2024] [Accepted: 07/19/2024] [Indexed: 08/13/2024]
Abstract
BACKGROUND The impact of the His bundle location and distance from the ablation site on ablation efficacy and complication risk remains unexplored. We determined the correlation between age, height, body mass index (BMI), and the His bundle location, and whether the distance between the His bundle and ablation target (DHIS-ABL) affects ablation safety and efficacy. METHODS Overall, 346 patients with atrioventricular nodal re-entrant tachycardia (AVNRT) and 96 with atrioventricular re-entrant tachycardia (AVRT) were retrospectively analyzed. The distance between the His bundle and the coronary sinus ostium (DHis-CS), the height of the His bundle (HHIS), and DHIS-ABL were measured. Electrocardiograms were obtained 3 months post-ablation to assess recurrence and complications. RESULTS Multiple linear regression showed that HHIS was negatively correlated with age in both groups. In AVNRT patients, DHIS-ABL was associated with age, height, and BMI; DHIS-CS was only negatively correlated with age. In AVRT patients, there was no significant correlation between the DHIS-ABL and age, height, or BMI. The recurrence rates in the AVNRT and AVRT groups were 0.9% and 8.7%, respectively. Subgroup analysis showed that patients with DHIS-ABL ≤ 10 mm had a higher recurrence rate than those with DHIS-ABL > 10 mm (p = .013). The incidence of third-degree atrioventricular block (AVB) complications was 0.2%. CONCLUSIONS HHIS was negatively correlated with age but not with height and BMI. The DHIS-ABL correlated with age, height, and BMI in AVNRT patients. A short DHIS-ABL led to a higher rate of supraventricular tachycardia recurrence; whether this affects AVB risk warrants further studies with larger sample sizes.
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Affiliation(s)
- Bangjiaxin Ren
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, P.R. China
| | - Ying Cao
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, P.R. China
| | - Jing Li
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, P.R. China
- Department of Cardiovascular, Sichuan Taikang Hospital, Chengdu, P.R. China
| | - Fanghui Li
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, P.R. China
| | - Chuanyun Wang
- Department of Cardiovascular, Yunyang County People's Hospital, Chongqing, P.R. China
| | - Meng Xiao
- Department of Cardiology, Neijiang Second People's Hospital, Neijiang, P.R. China
| | - Xianjin Hu
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, P.R. China
| | - Rui Zeng
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, P.R. China
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2
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Takahashi K, Kuwahara T, Makita T, Ito Y, Oyagi Y, Kadono K, Oshio T, Takahashi R. A novel approach to typical atrioventricular nodal reentrant tachycardia with high-resolution mapping using the CARTO 3 cardiac mapping system. J Interv Card Electrophysiol 2024; 67:807-816. [PMID: 37930505 DOI: 10.1007/s10840-023-01688-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 10/30/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND We hypothesized that high-resolution activation mapping during sinus rhythm (SR) in Koch's triangle (KT) can be used to describe the most delayed atrial potential around the atrioventricular node and evaluated whether ablation targeting of this potential is safe and effective for the treatment of patients with typical atrioventricular nodal reentrant tachycardia (AVNRT). METHODS We conducted a prospective, non-randomized, observational study using high-resolution activation mapping from the sinus node to KT with a PENTARAY or OCTARAY catheter using the CARTO 3 cardiac mapping system (Biosense Webster) during SR in 62 consecutive patients (22 men; age [mean ± standard deviation] = 55 ± 14 years) treated for typical AVNRT at our institution from August 2021 to March 2023. RESULTS In all cases, the most delayed atrial potential was observed near the His potential within KT. Ablation targeting of this potential helped successfully treat each case of AVNRT, with a junctional rhythm observed at the ablation site. Initial ablation was deemed successful in 55/62 patients (89%); in the remaining seven patients, lesion expansion resolved AVNRT. One procedural complication occurred, namely, a transient atrioventricular block lasting 45 s. One patient experienced a transient tachycardic episode by the 1-month follow-up, but no further episodes were noted up to the 1-year follow-up. CONCLUSION Activation mapping at KT during SR with the high-resolution CARTO system clearly revealed the most delayed atrial potential near the His potential within KT. Targeting this potential was a safe and effective treatment method for patients with typical AVNRT in our study.
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Affiliation(s)
- Kenta Takahashi
- Department of Cardiology, Tokyo Heart Rhythm Clinic, 3-20-1 Kasuya, Setagaya-ku, Tokyo, 157-0063, Japan.
| | - Taishi Kuwahara
- Department of Cardiology, Tokyo Heart Rhythm Clinic, 3-20-1 Kasuya, Setagaya-ku, Tokyo, 157-0063, Japan
| | - Toshio Makita
- Department of Cardiology, Tokyo Heart Rhythm Clinic, 3-20-1 Kasuya, Setagaya-ku, Tokyo, 157-0063, Japan
| | - Yayoi Ito
- Department of Clinical Engineering and Nursing, Tokyo Heart Rhythm Clinic, 3-20-1 Kasuya, Setagaya-ku, Tokyo, 157-0063, Japan
| | - Yoshimi Oyagi
- Department of Clinical Engineering and Nursing, Tokyo Heart Rhythm Clinic, 3-20-1 Kasuya, Setagaya-ku, Tokyo, 157-0063, Japan
| | - Kenta Kadono
- Department of Clinical Engineering and Nursing, Tokyo Heart Rhythm Clinic, 3-20-1 Kasuya, Setagaya-ku, Tokyo, 157-0063, Japan
| | - Takuya Oshio
- Department of Clinical Engineering and Nursing, Tokyo Heart Rhythm Clinic, 3-20-1 Kasuya, Setagaya-ku, Tokyo, 157-0063, Japan
| | - Ryo Takahashi
- Department of Clinical Engineering and Nursing, Tokyo Heart Rhythm Clinic, 3-20-1 Kasuya, Setagaya-ku, Tokyo, 157-0063, Japan
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3
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Di C, Wang Q, Wu Y, Li L, Lin W. The underrecognized and neglected compact atrioventricular nodal potential: clinical significance for preventing atrioventricular block during so-called slow pathway radiofrequency ablation. J Interv Card Electrophysiol 2024; 67:165-174. [PMID: 37330428 DOI: 10.1007/s10840-023-01597-7] [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: 03/21/2023] [Accepted: 06/12/2023] [Indexed: 06/19/2023]
Abstract
BACKGROUND The radiofrequency (RF) ablation target may be located at the compact atrioventricular node (AVN) region during so-called slow pathway (SP) RF ablation, potentially leading to transient or permanent atrioventricular block (AVB). However, related data are rare. METHODS Among 715 index consecutive patients who underwent RF ablation for atrioventricular nodal re-entry tachycardia, 17 patients subsequently experienced transient or permanent AVB and were included in this retrospective observational study. RESULTS Among the 17 patients, two patients (11.8%) developed transient first-degree AVB, four patients (23.5%) developed transient second-degree AVB, seven patients (41.2%) developed transient third-degree AVB, and four patients (23.5%) developed permanent third-degree AVB. During baseline sinus rhythm before the start of RF ablation, no His-bundle potential was recorded from the RF ablation catheter. During the so-called SP RF ablation that led to transient or permanent AVB, junctional rhythm with ventriculoatrial (VA) conduction block followed by subsequent AVB was observed in 14 of 17 patients (82.4%), and a low-amplitude, low-frequency hump-shaped atrial potential was recorded before the start of RF ablation in 7 of the 17 patients (41.2%). Direct AVB occurred in 3 of the 17 patients (17.6%), and a low-amplitude, low-frequency hump-shaped atrial potential was recorded before the start of RF ablation in all 3 patients. CONCLUSIONS The low-amplitude, low-frequency hump-shaped atrial potential recorded at the so-called SP region may reflect the electrogram of compact AVN activation, and RF ablation to this site heralds impending AVB even when a His-bundle potential is not recorded.
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Affiliation(s)
- Chengye Di
- Cardiac Electrophysiology Unit, First Department of Cardiology, TEDA International Cardiovascular Hospital, 3rd Street, Tianjin Economic-Technological Development Area, Tianjin, 300457, China
- College of Clinical Cardiology, Tianjin Medical University, Tianjin, China
- Cardiovascular Institute, Tianjin University, Tianjin, China
| | - Qun Wang
- Cardiac Electrophysiology Unit, First Department of Cardiology, TEDA International Cardiovascular Hospital, 3rd Street, Tianjin Economic-Technological Development Area, Tianjin, 300457, China
- College of Clinical Cardiology, Tianjin Medical University, Tianjin, China
- Cardiovascular Institute, Tianjin University, Tianjin, China
| | - Yanxi Wu
- Cardiac Electrophysiology Unit, First Department of Cardiology, TEDA International Cardiovascular Hospital, 3rd Street, Tianjin Economic-Technological Development Area, Tianjin, 300457, China
- College of Clinical Cardiology, Tianjin Medical University, Tianjin, China
- Cardiovascular Institute, Tianjin University, Tianjin, China
| | - Longlu Li
- Cardiac Electrophysiology Unit, First Department of Cardiology, TEDA International Cardiovascular Hospital, 3rd Street, Tianjin Economic-Technological Development Area, Tianjin, 300457, China
- College of Clinical Cardiology, Tianjin Medical University, Tianjin, China
- Cardiovascular Institute, Tianjin University, Tianjin, China
| | - Wenhua Lin
- Cardiac Electrophysiology Unit, First Department of Cardiology, TEDA International Cardiovascular Hospital, 3rd Street, Tianjin Economic-Technological Development Area, Tianjin, 300457, China.
- College of Clinical Cardiology, Tianjin Medical University, Tianjin, China.
- Cardiovascular Institute, Tianjin University, Tianjin, China.
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4
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Costa A, Marinelli A, Rauhe W, Martignani C, Ignatiuk B, Sabbatani P, Nangah R, Basso F, Molon G. Voltage mapping of Koch’s triangle in atrioventricular nodal reentrant tachycardia ablation. J Interv Card Electrophysiol 2022:10.1007/s10840-022-01432-5. [DOI: 10.1007/s10840-022-01432-5] [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: 08/16/2022] [Accepted: 11/15/2022] [Indexed: 11/24/2022]
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Miyazaki Y, Noda T, Miyamoto K, Nagase S, Aiba T, Kusano K. Atrioventricular nodal reentrant tachycardia in a nonagenarian-Triple traps of AV block. HeartRhythm Case Rep 2021; 7:442-445. [PMID: 34307025 PMCID: PMC8283418 DOI: 10.1016/j.hrcr.2021.03.021] [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: 11/18/2022] Open
Affiliation(s)
- Yuichiro Miyazaki
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
- Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Takashi Noda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
- Address reprint requests and correspondence: Dr Takashi Noda, Division of Arrhythmia, Department of Cardiology, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan.
| | - Koji Miyamoto
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Satoshi Nagase
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Takeshi Aiba
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
- Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
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6
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Chaumont C, Mirolo A, Savouré A, Godin B, Auquier N, Viart G, Hatrel A, Gillibert A, Eltchaninoff H, Anselme F. Very long‐term outcomes after catheter ablation of atrioventricular nodal reentrant tachycardia: How does cryoenergy differ from radiofrequency? J Cardiovasc Electrophysiol 2020; 31:3215-3222. [DOI: 10.1111/jce.14784] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/17/2020] [Accepted: 09/22/2020] [Indexed: 12/21/2022]
Affiliation(s)
- Corentin Chaumont
- Department of Cardiology Rouen University Hospital Rouen France
- UNIROUEN, INSERM U1096 FHU REMOD‐VHF Rouen France
| | - Adrian Mirolo
- Department of Cardiology Rouen University Hospital Rouen France
- UNIROUEN, INSERM U1096 FHU REMOD‐VHF Rouen France
| | - Arnaud Savouré
- Department of Cardiology Rouen University Hospital Rouen France
- UNIROUEN, INSERM U1096 FHU REMOD‐VHF Rouen France
| | - Bénédicte Godin
- Department of Cardiology Rouen University Hospital Rouen France
- UNIROUEN, INSERM U1096 FHU REMOD‐VHF Rouen France
| | - Nathanaël Auquier
- Department of Cardiology Groupe Hospitalier du Havre Le Havre France
| | - Guillaume Viart
- Department of Cardiology Rouen University Hospital Rouen France
| | - Amandine Hatrel
- Department of Cardiology Rouen University Hospital Rouen France
- Department of Cardiology Elbeuf Hospital Elbeuf France
| | - André Gillibert
- Department of Biostatistics Rouen University Hospital Rouen France
| | - Hélène Eltchaninoff
- Department of Cardiology Rouen University Hospital Rouen France
- UNIROUEN, INSERM U1096 FHU REMOD‐VHF Rouen France
| | - Frédéric Anselme
- Department of Cardiology Rouen University Hospital Rouen France
- UNIROUEN, INSERM U1096 FHU REMOD‐VHF Rouen France
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7
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Wang Y, Liu L, Lakin R, Polidovitch N, Liu G, Yang H, Yu M, Yan M, Zhao D, Backx PH, Sun H, He Y, Yang P. Revisiting right anterior oblique projections for the triangle of Koch: implications from computed tomography. BMC Cardiovasc Disord 2020; 20:383. [PMID: 32838758 PMCID: PMC7446209 DOI: 10.1186/s12872-020-01632-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 07/20/2020] [Indexed: 11/22/2022] Open
Abstract
Background Variability in the anatomy and orientation of the triangle of Koch (TK) complicates ablation procedures involving the atrioventricular (AV) node. We used CT angiography (CTA) to assess the anatomical TK orientation, the CS ostium direction, and the relationship between the two, and we validated an individualized CS-guided projection during ablation procedures. Methods In 104 patients without structural heart disease undergoing computed tomography (CT) angiography, TK orientations were determined in relation to the coronary sinus ostium (CSo) as well as two standard right anterior oblique (RAO) projection angles (30o and 45o) commonly used in ablation procedures. Results A CS-guided RAO projection (RAOCS) was shown to best track the orientation of the TK compared to RAO30° and 45°, with TK orientation strongly correlating with the CSo direction (r = 0.86, P < 0.001). In addition, the mean relative difference between the angle of the CSo and TK orientation was 5.54 ± 0.48°, consistent with a reduction in the degree of image shortening compared to traditional RAOs. Moreover, in vivo validation following ablation revealed that using a CS-guided projection limited the degree of on-screen image shortening compared to both the RAO30° and 45° in 25 patients with catheter ablation procedures. Conclusion In hearts with a normal structure, the CSo direction offers a reliable predictor of the TK orientation which can be used to guide the projection of the TK during ablation procedures.
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Affiliation(s)
- Yanjing Wang
- Radiology Department, China-Japan Union Hospital of Jilin University, 126 Xiantai street, Changchun, Jilin Province, 130033, China
| | - Lin Liu
- Radiology Department, China-Japan Union Hospital of Jilin University, 126 Xiantai street, Changchun, Jilin Province, 130033, China
| | - Robert Lakin
- Department of Biology, York University, 4700 Keele Street, Toronto, ON, Canada
| | - Nazari Polidovitch
- Department of Biology, York University, 4700 Keele Street, Toronto, ON, Canada
| | - Guohui Liu
- Cardiology Department, China-Japan Union Hospital of Jilin University, 126 Xiantai Street, Changchun, Jilin Province, 130033, China.,Jilin Provincial Precision Medicine Key Laboratory for Cardiovascular Genetic Diagnosis, Changchun, Jilin Province, 130033, China.,Jilin Provincial Cardiovascular Research Institute, Changchun, 130033, China
| | - Hongliang Yang
- Cardiology Department, China-Japan Union Hospital of Jilin University, 126 Xiantai Street, Changchun, Jilin Province, 130033, China.,Jilin Provincial Precision Medicine Key Laboratory for Cardiovascular Genetic Diagnosis, Changchun, Jilin Province, 130033, China.,Jilin Provincial Cardiovascular Research Institute, Changchun, 130033, China
| | - Ming Yu
- Cardiology Department, China-Japan Union Hospital of Jilin University, 126 Xiantai Street, Changchun, Jilin Province, 130033, China.,Jilin Provincial Precision Medicine Key Laboratory for Cardiovascular Genetic Diagnosis, Changchun, Jilin Province, 130033, China.,Jilin Provincial Cardiovascular Research Institute, Changchun, 130033, China
| | - Mingzhou Yan
- Cardiology Department, China-Japan Union Hospital of Jilin University, 126 Xiantai Street, Changchun, Jilin Province, 130033, China.,Jilin Provincial Precision Medicine Key Laboratory for Cardiovascular Genetic Diagnosis, Changchun, Jilin Province, 130033, China.,Jilin Provincial Cardiovascular Research Institute, Changchun, 130033, China
| | - Dong Zhao
- Cardiology Department, China-Japan Union Hospital of Jilin University, 126 Xiantai Street, Changchun, Jilin Province, 130033, China.,Jilin Provincial Precision Medicine Key Laboratory for Cardiovascular Genetic Diagnosis, Changchun, Jilin Province, 130033, China.,Jilin Provincial Cardiovascular Research Institute, Changchun, 130033, China
| | - Peter H Backx
- Department of Biology, York University, 4700 Keele Street, Toronto, ON, Canada
| | - Huan Sun
- Cardiology Department, China-Japan Union Hospital of Jilin University, 126 Xiantai Street, Changchun, Jilin Province, 130033, China. .,Jilin Provincial Precision Medicine Key Laboratory for Cardiovascular Genetic Diagnosis, Changchun, Jilin Province, 130033, China. .,Jilin Provincial Cardiovascular Research Institute, Changchun, 130033, China.
| | - Yuquan He
- Cardiology Department, China-Japan Union Hospital of Jilin University, 126 Xiantai Street, Changchun, Jilin Province, 130033, China. .,Jilin Provincial Precision Medicine Key Laboratory for Cardiovascular Genetic Diagnosis, Changchun, Jilin Province, 130033, China. .,Jilin Provincial Cardiovascular Research Institute, Changchun, 130033, China.
| | - Ping Yang
- Cardiology Department, China-Japan Union Hospital of Jilin University, 126 Xiantai Street, Changchun, Jilin Province, 130033, China.,Jilin Provincial Precision Medicine Key Laboratory for Cardiovascular Genetic Diagnosis, Changchun, Jilin Province, 130033, China.,Jilin Provincial Cardiovascular Research Institute, Changchun, 130033, China
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8
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Deshpande SA, Udyavar AR. Ablation of atrioventricular-nodal-reentrant- tachycardia in a patient with left-sided superior vena cava and dilated coronary sinus. J Postgrad Med 2020; 66:159-161. [PMID: 32567577 PMCID: PMC7542059 DOI: 10.4103/jpgm.jpgm_626_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Atrioventricular (AV)-nodal-reentrant-tachycardia is a rare association in a patient with persistent left-sided superior vena cava and dilated coronary sinus. There are a few inherent difficulties in ablation in this condition, viz., difficulty in localization of good site for ablation and difficulty in stabilization of the ablation catheter at the designated site, making it difficult to produce transmural lesions and increasing risk of producing AV block. We hereby present a case highlighting the difficulties and possible solutions for them.
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Affiliation(s)
- S A Deshpande
- Department of Cardiology, Jagjivan Ram Western Railway Hospital, Mumbai, Maharashtra, India
| | - A R Udyavar
- Department of Cardiology, Jagjivan Ram Western Railway Hospital, Mumbai, Maharashtra, India
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9
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Iizuka T, Nakajima T, Tamura S, Hasegawa H, Kobari T, Nakahara S, Kurabayashi M, Kaneko Y. Simple differential entrainment screens ablation strategy for slow-fast atrioventricular nodal reentrant tachycardia. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2020; 43:671-679. [PMID: 32469105 DOI: 10.1111/pace.13946] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 04/13/2020] [Accepted: 05/06/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Ablation of slow-fast atrioventricular nodal reentrant tachycardia (S/F-AVNRT) is occasionally refractory. We hypothesized that the site of ablation for curing S/F-AVNRT can be screened by simple differential atrial entrainment pacing (EP) from the high right atrium (HRA) and proximal coronary sinus (prox-CS). METHODS We enrolled 43 patients with S/F-AVNRT who underwent successful differential atrial EP followed by successful ablation of slow pathway (SP) using step-wise approach, and compared the atrio-His (A-H) interval at the recording of His bundle immediately after EP from the HRA [A-H(HRA)], with the interval between atrial deflection at the prox-CS and His bundle electrogram after EP at an identical cycle length from the prox-CS [A-H (prox-CS)]. RESULTS A typical A-H(CS) shorter than A-H(HRA), consistent with typical SP conduction, was observed in 39 patients (91%), and an atypical A-H(HRA) shorter than A-H(CS) was observed in 4 patients (9%). Successful ablation was obtained at the posteroseptum/midseptum in 32/7 patients with typical responses but only at the midseptum in all 4 patients with atypical responses (P = .0027). The atypical responses predicted a necessity for ablation at the midseptum, with positive and negative predictive values of 100% and 82%, respectively. The mechanism of an atypical response remains unclear but may involve an anatomical variation of Koch's triangle and/or the participation of a variant of the SP, including the superior SP, over which retrograde conduction was observed more frequently in patients with atypical responses (P = .0013). CONCLUSIONS Differential atrial EP predicts the ablation site for successfully curing S/F-AVNRT.
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Affiliation(s)
- Takashi Iizuka
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Tadashi Nakajima
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Shuntaro Tamura
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Hiroshi Hasegawa
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Takashi Kobari
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Shiro Nakahara
- Department of Cardiology, Dokkyo Medical University Saitama Hospital, Koshigaya, Saitama, Japan
| | - Masahiko Kurabayashi
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Yoshiaki Kaneko
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
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10
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A comprehensive review of the anatomical variations in the right atrium and their clinical significance. TRANSLATIONAL RESEARCH IN ANATOMY 2019. [DOI: 10.1016/j.tria.2019.100046] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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11
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Clinical and electrophysiological characteristics of idiopathic ventricular arrhythmias originating from the slow pathway region. Heart Rhythm 2019; 16:1421-1428. [DOI: 10.1016/j.hrthm.2019.06.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Indexed: 11/21/2022]
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12
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Garweg C, De Buck S, Vandenberk B, Willems R, Ector J. High-Detailed evaluation of the right atrial anatomy by three-dimensional rotational angiography during ablation procedures for atrioventricular nodal reentrant tachycardia and atrial flutter. SCAND CARDIOVASC J 2018; 52:268-274. [PMID: 30445881 DOI: 10.1080/14017431.2018.1546893] [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] [Indexed: 10/27/2022]
Abstract
AIM 3D Rotational angiography (3DRA) allows for detailed reconstruction of atrial anatomy and is often used to facilitate pulmonary vein isolation. This study aimed to reappraise the anatomy of the right atrium (RA) using 3DRA, specifically looking at Koch's triangle and the cavotricuspid isthmus (CTI) in atrio-ventricular reentrant tachycardia (AVNRT) and atrial flutter (AFl) ablation. METHODS AND RESULTS 3DRA was performed in 97 patients: AVNRT = 51 and AFl = 46. Dimensions of Koch's triangle and CTI were highly variable between individuals but were not different in both ablation groups. RA volume was significantly larger in AFl patients (p = .004) while indexed RA volume to the body surface area (RAVI) was lightly different (p = .024). In univariate Cox analysis, age (p = .003), RAVI (p < .001) and previous ablation of AFl (p = .003) were predictors of AF occurrence . In multivariate Cox analysis, RAVI was the only independent predictor of AF occurrence. RAVI >80 ml/m2 was a strong predictor for AF during follow-up. CONCLUSION 3DRA allows for detailed per-procedural evaluation of RA anatomy and revealed a great variability in Koch's triangle and CTI dimensions and morphology. RA enlargement as measured by RAVI was an independent predictor for AF occurrence during follow-up.
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Affiliation(s)
- Christophe Garweg
- a Department of Cardiovascular Sciences , University of Leuven , Leuven , Belgium.,b Department of Cardiology , University Hospitals Leuven , Leuven , Belgium
| | - Stijn De Buck
- b Department of Cardiology , University Hospitals Leuven , Leuven , Belgium
| | - Bert Vandenberk
- a Department of Cardiovascular Sciences , University of Leuven , Leuven , Belgium.,b Department of Cardiology , University Hospitals Leuven , Leuven , Belgium
| | - Rik Willems
- a Department of Cardiovascular Sciences , University of Leuven , Leuven , Belgium.,b Department of Cardiology , University Hospitals Leuven , Leuven , Belgium
| | - Joris Ector
- a Department of Cardiovascular Sciences , University of Leuven , Leuven , Belgium.,b Department of Cardiology , University Hospitals Leuven , Leuven , Belgium
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13
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Fragakis N, Krexi L, Kyriakou P, Sotiriadou M, Lazaridis C, Karamanolis A, Dalampyras P, Tsakiroglou S, Skeberis V, Tsalikakis D, Vassilikos V. Electrophysiological markers predicting impeding AV-block during ablation of atrioventricular nodal reentry tachycardia. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2017; 41:7-13. [DOI: 10.1111/pace.13245] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 11/08/2017] [Accepted: 11/09/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Nikolaos Fragakis
- Third Department of Cardiology; Hippokration Hospital; Medical School; Aristotle University of Thessaloniki; Thessaloniki Greece
| | - Lydia Krexi
- Third Department of Cardiology; Hippokration Hospital; Medical School; Aristotle University of Thessaloniki; Thessaloniki Greece
| | - Panagiota Kyriakou
- Third Department of Cardiology; Hippokration Hospital; Medical School; Aristotle University of Thessaloniki; Thessaloniki Greece
| | - Melani Sotiriadou
- Third Department of Cardiology; Hippokration Hospital; Medical School; Aristotle University of Thessaloniki; Thessaloniki Greece
| | - Charalambos Lazaridis
- Third Department of Cardiology; Hippokration Hospital; Medical School; Aristotle University of Thessaloniki; Thessaloniki Greece
| | - Athanasios Karamanolis
- Third Department of Cardiology; Hippokration Hospital; Medical School; Aristotle University of Thessaloniki; Thessaloniki Greece
| | - Panagiotis Dalampyras
- Third Department of Cardiology; Hippokration Hospital; Medical School; Aristotle University of Thessaloniki; Thessaloniki Greece
| | - Stelios Tsakiroglou
- Third Department of Cardiology; Hippokration Hospital; Medical School; Aristotle University of Thessaloniki; Thessaloniki Greece
| | - Vassilios Skeberis
- Third Department of Cardiology; Hippokration Hospital; Medical School; Aristotle University of Thessaloniki; Thessaloniki Greece
| | - Dimitrios Tsalikakis
- Department of Informatics and Telecommunications; University of Western Macedonia; Macedonia Greece
| | - Vassilios Vassilikos
- Third Department of Cardiology; Hippokration Hospital; Medical School; Aristotle University of Thessaloniki; Thessaloniki Greece
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14
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Elongated ascending aorta predicts a short distance between his-bundle potential recording site and coronary sinus ostium. J Arrhythm 2017; 33:318-323. [PMID: 28765763 PMCID: PMC5529593 DOI: 10.1016/j.joa.2017.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Revised: 03/15/2017] [Accepted: 04/03/2017] [Indexed: 12/02/2022] Open
Abstract
Background When performing catheter ablation of atrioventricular nodal reentrant tachycardia (AVNRT), it can be difficult to maintain a safe distance from the His recording site to avoid AV block in patients with a short distance between this recording site to the coronary sinus (CS) ostium (small triangle of Koch [TOK]). In this study, we sought to identify parameters predicting small TOK and test these parameters in patients undergoing AVNRT catheter ablation. Methods Twenty-eight patients who underwent catheter ablation of atrial fibrillation using a three-dimensional (3D) electroanatomical mapping system (EAM) with computed tomography (CT) merge (23 males; mean age, 65.8±12.1 years) were included. The shortest distance between the CS ostium and His recording sites (His-CSd) was measured on the EAM. Aortic (Ao) unfolding in chest X-ray scan, Ao angle to the LV, Ao length, Ao to the right ventricular distance, size of the Valsalva in the CT scan, and parameters of echocardiogram were evaluated. The identified parameters were subsequently tested as predictors for small TOK in patients undergoing AVNRT ablation. Results The size of TOK was associated with Ao length (r = −0.70, p<0.01), left ventricular end-systolic dimension (LVDs) (r = −0.51, p<0.01), and Ao unfolding. In patients with AVNRT, only Ao unfolding predicted a smaller TOK. Conclusions Small TOK was associated with longer Ao, larger LVDs, and Ao unfolding. Of these, Ao unfolding was associated with smaller TOK in patients with AVNRT.
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15
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Kiuchi K, Fukuzawa K, Shumpei M, Nishii T. The inferior displacement of the His bundle and fast pathway in a patient with common type atrioventricular nodal tachycardia: Three-dimensional computed tomography analysis. J Arrhythm 2017; 33:147-149. [PMID: 28416984 PMCID: PMC5388057 DOI: 10.1016/j.joa.2016.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 07/13/2016] [Accepted: 07/25/2016] [Indexed: 11/29/2022] Open
Abstract
A 66-year-old woman with palpitations was referred to our center for catheter ablation due to drug-refractory, common type atrioventricular nodal tachycardia (AVNRT). A selective slow pathway ablation was attempted. A fast junctional rhythm with transient ventriculoatrial block followed by transient prolongation of the A–H interval occurred immediately after the radiofrequency (RF) application at the coronary sinus ostium (CSOS) level. To assess the location of the fast pathway and His bundle, we sought to visualize the anatomy of the triangle of Koch (TOK) by three-dimensional computed tomography (CT).
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Affiliation(s)
- Kunihiko Kiuchi
- Section of Arrhythmia, Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-chou chuou-ku, Kobe, Hyogo, Japan
- Corresponding author. Fax: +81 78 382 5859.
| | - Koji Fukuzawa
- Section of Arrhythmia, Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-chou chuou-ku, Kobe, Hyogo, Japan
| | - Mori Shumpei
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-chou chuou-ku, Kobe, Hyogo, Japan
| | - Tatsuya Nishii
- Department of Radiology, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-chou chuou-ku, Kobe, Hyogo, Japan
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16
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Bhaskaran A, Albarri M, Ross N, Al Raisi S, Samanta R, Roode L, Nadri F, Ng J, Thomas S, Thiagalingam A, Kovoor P. Slow Pathway Radiofrequency Ablation Using Magnetic Navigation: A Description of Technique and Retrospective Case Analysis. Heart Lung Circ 2017; 26:1297-1302. [PMID: 28318819 DOI: 10.1016/j.hlc.2017.01.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Revised: 12/18/2016] [Accepted: 01/15/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND The Magnetic Navigation System (MNS) catheter was shown to be stable in the presence of significant cardiac wall motion and delivered more effective lesions compared to manual control. This stability could potentially make AV junctional re-entrant tachycardia (AVNRT) ablation safer. The aim of this study is to describe the method of mapping and ablation of AVNRT with MNS and 3-D electro-anatomical mapping system (CARTO, Biosense Webster, Diamond bar, CA, USA) anatomical mapping, with a view to improve the safety of ablation. METHODS The method of precise mapping and ablation with MNS is described. Consecutive AVNRT cases (n=30) from 2012 January to 2015 November, in which magnetic navigation was used, are analysed. RESULTS Ablation was successful in 27 (90%) out of 30 patients. In three cases, ablation was abandoned due to the proximity of the three-dimensional His image to the potential ablation site. No complications, including AV nodal injury, occurred. The distance from the nearest His position to successful ablation site in both LAO and RAO projections of CARTO images was 26.4±8.8 and 27±7.7mm respectively. Only in two (9%) patients, ablation needed to be extended superior to the plane of coronary sinus ostium, towards the His bundle region, to achieve slow pathway modification. CONCLUSION AVNRT ablation with MNS allows for accurate mapping of the AV node and stable ablation at a safe distance, which could help avoid AV nodal injury. We recommend this modality for younger patients with AVNRT.
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Affiliation(s)
- Abhishek Bhaskaran
- Cardiology Department, Westmead Hospital, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Maha Albarri
- Cardiology Department, Westmead Hospital, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Neil Ross
- Cardiology Department, Westmead Hospital, Sydney, NSW, Australia
| | - Sara Al Raisi
- Cardiology Department, Westmead Hospital, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Rahul Samanta
- Cardiology Department, Westmead Hospital, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | | | - Fazlur Nadri
- Cardiology Department, Westmead Hospital, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Jeanette Ng
- Cardiology Department, Westmead Hospital, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Stuart Thomas
- Cardiology Department, Westmead Hospital, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Aravinda Thiagalingam
- Cardiology Department, Westmead Hospital, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Pramesh Kovoor
- Cardiology Department, Westmead Hospital, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia.
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Klimek-Piotrowska W, Holda MK, Koziej M, Salapa K, Piatek K, Holda J. Geometry of Koch's triangle. Europace 2017; 19:452-457. [PMID: 27247009 DOI: 10.1093/europace/euw022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Accepted: 01/20/2016] [Indexed: 11/12/2022] Open
Abstract
Aims The first aim of this study was to determine the size of the Koch's triangle. The second one was to investigate relation between its dimensions and other individual-specific and heart-specific parameters as well as to create universal formula to estimate triangle dimensions based on these parameters. Methods and results This study is a prospective one, presenting 120 randomly selected autopsied hearts dissected from adult humans (Caucasian) of both sexes (31.7% females), with mean age of 49.3 ± 17.4 years. The length of triangle sides and angles were measured and the triangle area was calculated as well. Sixteen additional heart parameters were measured in order to analyse potential relationship between the dimensions of Koch's triangle and other dimensions of the heart, using linear regression analysis. The mean (±SD) length of the anterior edge was approximated to 18.0 ± 3.8 mm, the posterior edge to 20.3 ± 4.3 mm, and the basal edge to 18.5 ± 4.0 mm. The average values of the apex angle, the Eustachian angle, and the septal leaflet angle were 58.0 ± 14.4°, 53.8 ± 10.6°, and 67.6 ± 14.4°, respectively. The mean value of the Koch's triangle area was 151.5 ± 55.8 mm2. The 95th percentile of triangle's height (the distance from the apex to the coronary sinus) was 21.8 mm. Conclusion Mean values and proportions of triangle's sides and angles were presented. Koch's triangle showed considerable individual variations in size. The dimensions of the triangle were strongly independent from individual-specific and heart-specific morphometric parameters; however, the maximum triangle's height can be estimated as 22 mm.
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Affiliation(s)
| | - Mateusz K Holda
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034 Cracow, Poland
| | - Mateusz Koziej
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034 Cracow, Poland
| | - Kinga Salapa
- Department of Bioinformatics and Telemedicine, Jagiellonian University Medical College, Cracow, Poland
| | - Katarzyna Piatek
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034 Cracow, Poland
| | - Jakub Holda
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034 Cracow, Poland
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Saremi F, Hassani C, Sánchez-Quintana D. Septal Atrioventricular Junction Region: Comprehensive Imaging in Adults. Radiographics 2016; 36:1966-1986. [DOI: 10.1148/rg.2016160010] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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19
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Mills MF, Motonaga KS, Trela A, Dubin AM, Avasarala K, Ceresnak SR. Is There a Difference in Tachycardia Cycle Length during SVT in Children with AVRT and AVNRT? PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2016; 39:1206-1212. [PMID: 27653639 DOI: 10.1111/pace.12950] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2016] [Revised: 06/07/2016] [Accepted: 08/23/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND There are limited adult data suggesting the tachycardia cycle length (TCL) of atrioventricular reentry tachycardia (AVRT) is shorter than atrioventricular nodal reentry tachycardia (AVNRT), though little data exist in children. We sought to determine if there is a difference in TCL between AVRT and AVNRT in children. METHODS A single-center retrospective review of children with supraventricular tachycardia (SVT) from 2000 to 2015 was performed. INCLUSION CRITERIA Age ≤ 18 years, invasive electrophysiology study (EPS) confirming AVRT or AVNRT. EXCLUSION CRITERIA Atypical AVNRT, congenital heart disease, antiarrhythmic medication use at time of EPS. Data were compared between patients with AVRT and AVNRT via t-test, χ2 test, and linear regression. RESULTS A total of 835 patients were included (12 ± 4 years, 52 ± 31 kg, TCL 321 ± 55 ms), 539 (65%) with AVRT (270 Wolff-Parkinson-White, 269 concealed pathways) and 296 (35%) with AVNRT. Patients with AVRT were younger (11.7 ± 4.1 years vs 13.0 ± 3.6 years, P < 0.001) and smaller (49 ± 22 kg vs 57 ± 43 kg, P < 0.001). In the baseline state, the TCL was shorter in AVRT than AVRNT (329 ± 51 ms vs 340 ± 60 ms, P = 0.04). In patients requiring isoproterenol to induce SVT, there was no difference in TCL (290 ± 49 ms vs 297 ± 49 ms, P = 0.26). When controlling for age, there was no difference in TCL between AVRT and AVNRT at baseline or on isoproterenol. The regression equation for TCL in the baseline state was TCL = 290 + 4 (age), indicating the TCL will increase by 4 ms above a baseline of 290 ms for each year of life. CONCLUSIONS When controlling for age, there is no difference in the TCL between AVRT and AVNRT in children. Age, not tachycardia mechanism, is the most significant factor in predicting TCL.
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Affiliation(s)
- Marcos F Mills
- Department of Pediatrics, Residency Training Program, Lucile Packard Children's Hospital, Stanford University, Palo Alto, California
| | - Kara S Motonaga
- Division of Pediatric Cardiology, Pediatric Electrophysiology, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University, Palo Alto, California
| | - Anthony Trela
- Division of Pediatric Cardiology, Pediatric Electrophysiology, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University, Palo Alto, California
| | - Anne M Dubin
- Division of Pediatric Cardiology, Pediatric Electrophysiology, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University, Palo Alto, California
| | - Kishor Avasarala
- Division of Pediatric Cardiology, Pediatric Electrophysiology, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University, Palo Alto, California
| | - Scott R Ceresnak
- Division of Pediatric Cardiology, Pediatric Electrophysiology, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University, Palo Alto, California
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Electroanatomically estimated length of slow pathway in atrioventricular nodal reentrant tachycardia. Heart Vessels 2015; 29:817-24. [PMID: 24121973 PMCID: PMC4226935 DOI: 10.1007/s00380-013-0424-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2013] [Accepted: 09/27/2013] [Indexed: 11/02/2022]
Abstract
The length of the slow pathway (SP-L) in atrioventricular (AV) nodal reentrant tachycardia (NRT) has never been measured clinically. We studied the relationship among (a) SP-L, i.e., the distance between the most proximal His bundle (H) recording and the most posterior site of radiofrequency (RF) delivery associated with a junctional rhythm, (b) the length of Koch’s triangle (Koch-L), (c) the conduction time over the slow pathway (SP-T), measured by the AH interval during AVNRT at baseline, and (d) the distance between H and the site of successful ablation (SucABL-L) in 26 women and 20 men (mean age 64.6 ± 11.6 years), using a stepwise approach and an electroanatomic mapping system (EAMS). SP-L (15.0 ± 5.8 mm) was correlated with Koch-L (18.6 ± 5.6 mm; R 2 = 0.1665, P < 0.005), SP-T (415 ± 100 ms; R 2 = 0.3425, P = 0.036), and SucABL-L (11.6 ± 4.7 mm; R 2 = 0.5243, P < 0.0001). The site of successful ablation was located within 10 mm of the posterior end of the SP in 38 patients (82.6 %). EAMS-guided RF ablation, using a stepwise approach, revealed individual variations in SP-L related to the size of Koch’s triangle and AH interval during AVNRT. Since the site of successful ablation was also correlated with SP-L and was usually located near the posterior end of the SP, ablating anteriorly, away from the posterior end, is not a prerequisite for the success of ablation procedures.
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21
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Jauregui-Abularach ME, Bazan V, Martí-Almor J, Cian D, Vallès E, Benito B, Meroño O, Bruguera-Cortada J. Caracterización de la vía lenta nodular en pacientes con taquicardia por reentrada nodular: implicaciones clínicas para guiar la ablación. Rev Esp Cardiol 2015. [DOI: 10.1016/j.recesp.2014.04.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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22
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Jauregui-Abularach ME, Bazan V, Martí-Almor J, Cian D, Vallès E, Benito B, Meroño O, Bruguera-Cortada J. Characterization of the nodal slow pathway in patients with nodal reentrant tachycardia: clinical implications for guiding ablation. ACTA ACUST UNITED AC 2014; 68:298-304. [PMID: 25440045 DOI: 10.1016/j.rec.2014.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2013] [Accepted: 04/04/2014] [Indexed: 11/15/2022]
Abstract
INTRODUCTION AND OBJECTIVES Nodal slow pathway ablation is the treatment of choice for nodal reentrant tachycardia. No demographic, anatomic, or electrophysiologic variables have been reported to predict an exact location of the slow pathway in the atrioventricular node or its proximity to the fast pathway. The purpose of this study was to analyze these variables. METHODS The study prospectively included 54 patients (17 men; mean age, 55 [16] years) who had undergone successful slow pathway ablation. The refractory periods of both pathways and their differential conduction time were measured, and calculations were performed to obtain the distance from the His-bundle region (location of the fast pathway) to the coronary sinus ostium (to estimate the anteroposterior length of the triangle of Koch) and to the slow pathway area. RESULTS The differential conduction time (139 [98] ms) did not correlate with the His-coronary sinus distance (19 [6] mm; P=.6) or the His-slow pathway distance (14 [4] mm; P=.4). When the His-coronary sinus distance was larger, the His-slow pathway distance was also larger (r=0.652; P<.01) and the anatomic correlation between the triangle dimensions and the separation between the two pathways was confirmed. In patients older than 70 years, smaller triangle sizes and a shorter distance between both pathways were observed (P<.001). CONCLUSIONS A greater anteroposterior dimension of the triangle of Koch is associated with a slow-pathway location farther from the fast pathway. In elderly patients the two pathways are closer together (higher risk of atrioventricular block).
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Affiliation(s)
| | - Victor Bazan
- Unidad de Arritmias, Servicio de Cardiología, Hospital del Mar, Barcelona, Spain
| | - Julio Martí-Almor
- Unidad de Arritmias, Servicio de Cardiología, Hospital del Mar, Barcelona, Spain
| | - Debora Cian
- Unidad de Arritmias, Servicio de Cardiología, Hospital del Mar, Barcelona, Spain
| | - Ermengol Vallès
- Unidad de Arritmias, Servicio de Cardiología, Hospital del Mar, Barcelona, Spain
| | - Begoña Benito
- Unidad de Arritmias, Servicio de Cardiología, Hospital del Mar, Barcelona, Spain
| | - Oona Meroño
- Unidad de Arritmias, Servicio de Cardiología, Hospital del Mar, Barcelona, Spain
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Giedrimas E, Goldberger JJ. Catheter ablation for supraventricular tachycardias: contemporary issues. Future Cardiol 2014; 9:581-96. [PMID: 23834697 DOI: 10.2217/fca.13.26] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
The treatment of cardiac arrhythmias has evolved significantly over the last 30 years. Understanding of arrhythmia mechanisms has led to pharmacologic therapies, surgical interventions and the widely used percutaneous catheter ablation techniques. The focus of this review is centered on the current catheter ablation therapies available for supraventricular tachycardia. We will discuss current management strategies including challenges when considering catheter ablation therapy for management of supraventricular tachycardias: atrioventricular nodal reentrant tachycardia, atrioventricular reentrant tachycardia utilizing an accessory pathway, atrial tachycardia and atrial flutter. Selected contemporary issues related to supraventricular tachycardia physiology, ablation approaches and ablation outcomes and complications will be discussed. Future goals for electrophysiologists are to continue to improve procedural safety and efficiency, while maintaining the impressive success rates that have been achieved.
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Affiliation(s)
- Evaldas Giedrimas
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, 251 East Huron Street, Feinberg 8-503E, Chicago, IL 60611, USA
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24
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Anatomical and electrophysiological variations of Koch's triangle and the impact on the slow pathway ablation in patients with atrioventricular nodal reentrant tachycardia: a study using 3D mapping. J Interv Card Electrophysiol 2013; 37:111-20. [PMID: 23408048 DOI: 10.1007/s10840-012-9769-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2012] [Accepted: 11/29/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE This study aimed to reveal individual variations in Koch's triangle using NavX and to evaluate the efficacy of the NavX-guided slow pathway ablation. METHODS A regional geometry around Koch's triangle was constructed in 42 consecutive patients with atrioventricular nodal reentrant tachycardia (AVNRT), and a bipolar electrogram map was created with 72 ± 30 sampling points during sinus rhythm to identify sites with Haissaguerre's slow potentials (SPs) and His bundle electrograms (HBEs) to examine the anatomical and electrical variations. Radiofrequency ablation was performed at the most prominent SP recording site. The acute results and long-term outcome were examined in comparison to another 42 consecutive patients who underwent a conventional fluoroscopy-guided slow pathway ablation in the previous months. RESULTS The size of Koch's triangle and the coronary sinus ostium varied over a wide range of 132 to 490 and 69 to 346 mm(2), respectively. HBEs were recorded linearly along the antero-septal right atrium (n = 29) or deviated downward toward the midseptum (n = 13, 31 %). The SPs were always distributed below the lowest HBE recording site. The NavX-guided ablation eliminated AVNRT with a median of 1 radiofrequency pulse, 9.1 ± 4.6 min of fluoroscopy, and 49 ± 14 min of procedure time, all of which were significantly smaller than those in fluoroscopy-guided ablation. No procedure-related complications or long-term recurrence was noted in either group. CONCLUSION Koch's triangle varies in terms of the size and electrogram distribution, and the NavX-guided slow pathway ablation overcomes the diversity and seems more effective than fluoroscopy-guided ablation.
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Pandozi C, Ficili S, Galeazzi M, Lavalle C, Russo M, Pandozi A, Venditti F, Pristipino C, Verbo B, Santini M. Propagation of the Sinus Impulse Into the Koch Triangle and Localization, Timing, and Origin of the Multicomponent Potentials Recorded in This Area. Circ Arrhythm Electrophysiol 2011; 4:225-34. [DOI: 10.1161/circep.110.957381] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
The presence of a conduction block at the level of the Koch triangle (KT) and the origin of the multicomponent potentials inside this area are controversial issues. We investigated the propagation of the sinus impulse into the KT and the characteristics of multicomponent potentials recorded in that area in patients with and without atrioventricular nodal reentrant tachycardia (AVNRT).
Methods and Results—
Thirty-two patients (16 with AVNRT, 16 without AVNRT) underwent a sinus rhythm electroanatomic mapping of the right atrium (RA). Conduction velocities in the RA and in the KT were evaluated quantitatively on activation maps and qualitatively on isochronal and propagation maps. The presence, location, and timing of different types of multicomponent potentials were evaluated. A mean of 149±44 points were sampled in the RA, whereas a mean of 79±21 points were collected inside the KT. Propagation block at the level of crista terminalis was not found in any patient, whereas slow conduction inside the KT was found in all (median conduction velocity, 122 cm/s [110 to 135 cm/s] outside KT versus 60 cm/s [48 to 75 cm/s] inside KT;
P
<0.0001). Jackman potentials were identified inside KT in almost all the patients and were invariably found on the line of collision between the wavefronts activating the KT in opposite directions.
Conclusions—
No conduction block was detected inside the KT in patients with and without AVNRT. Conduction slowing was demonstrated during propagation of the sinus impulse inside the KT. The genesis of the Jackman potential may be related to the collision of the wavefronts activating KT in opposite directions.
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Affiliation(s)
- Claudio Pandozi
- From the Department of Cardiology (C. Pandozi, S.F., M.G., C.L., M.R., A.P., F.V., B.V., M.S.) and Clinical Research Centre and Department of Cardiology (C. Pristipino), San Filippo Neri Hospital, Rome, Italy
| | - Sabina Ficili
- From the Department of Cardiology (C. Pandozi, S.F., M.G., C.L., M.R., A.P., F.V., B.V., M.S.) and Clinical Research Centre and Department of Cardiology (C. Pristipino), San Filippo Neri Hospital, Rome, Italy
| | - Marco Galeazzi
- From the Department of Cardiology (C. Pandozi, S.F., M.G., C.L., M.R., A.P., F.V., B.V., M.S.) and Clinical Research Centre and Department of Cardiology (C. Pristipino), San Filippo Neri Hospital, Rome, Italy
| | - Carlo Lavalle
- From the Department of Cardiology (C. Pandozi, S.F., M.G., C.L., M.R., A.P., F.V., B.V., M.S.) and Clinical Research Centre and Department of Cardiology (C. Pristipino), San Filippo Neri Hospital, Rome, Italy
| | - Maurizio Russo
- From the Department of Cardiology (C. Pandozi, S.F., M.G., C.L., M.R., A.P., F.V., B.V., M.S.) and Clinical Research Centre and Department of Cardiology (C. Pristipino), San Filippo Neri Hospital, Rome, Italy
| | - Angela Pandozi
- From the Department of Cardiology (C. Pandozi, S.F., M.G., C.L., M.R., A.P., F.V., B.V., M.S.) and Clinical Research Centre and Department of Cardiology (C. Pristipino), San Filippo Neri Hospital, Rome, Italy
| | - Franco Venditti
- From the Department of Cardiology (C. Pandozi, S.F., M.G., C.L., M.R., A.P., F.V., B.V., M.S.) and Clinical Research Centre and Department of Cardiology (C. Pristipino), San Filippo Neri Hospital, Rome, Italy
| | - Christian Pristipino
- From the Department of Cardiology (C. Pandozi, S.F., M.G., C.L., M.R., A.P., F.V., B.V., M.S.) and Clinical Research Centre and Department of Cardiology (C. Pristipino), San Filippo Neri Hospital, Rome, Italy
| | - Brunella Verbo
- From the Department of Cardiology (C. Pandozi, S.F., M.G., C.L., M.R., A.P., F.V., B.V., M.S.) and Clinical Research Centre and Department of Cardiology (C. Pristipino), San Filippo Neri Hospital, Rome, Italy
| | - Massimo Santini
- From the Department of Cardiology (C. Pandozi, S.F., M.G., C.L., M.R., A.P., F.V., B.V., M.S.) and Clinical Research Centre and Department of Cardiology (C. Pristipino), San Filippo Neri Hospital, Rome, Italy
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Tseng TW, Hu YF, Tsai CF, Tsao HM, Tai CT, Lin YJ, Chang SL, Lo LW, Lee PC, Li CH, Chao TF, Suenari K, Lin YK, Chiang CE, Chen SA. Paradoxical Aging Changes of the Atrioventricular Nodal Properties in Patients With Atrioventricular Nodal Re-Entrant Tachycardia. Circ J 2011; 75:1581-4. [DOI: 10.1253/circj.cj-10-1205] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Tzu-Wei Tseng
- Division of Cardiology, Taipei Veterans General Hospital
| | - Yu-Feng Hu
- Division of Cardiology, Taipei Veterans General Hospital
- Department of Medicine and Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University School of Medicine
| | | | - Hsuan-Ming Tsao
- Division of Cardiology, National Yang-Ming University Hospital
| | - Ching-Tai Tai
- Division of Cardiology, Taipei Veterans General Hospital
- Department of Medicine and Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University School of Medicine
| | - Yenn-Jiang Lin
- Division of Cardiology, Taipei Veterans General Hospital
- Department of Medicine and Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University School of Medicine
| | - Shih-Lin Chang
- Division of Cardiology, Taipei Veterans General Hospital
- Department of Medicine and Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University School of Medicine
| | - Li-Wei Lo
- Division of Cardiology, Taipei Veterans General Hospital
- Department of Medicine and Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University School of Medicine
| | - Pi-Chang Lee
- Department of Medicine and Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University School of Medicine
- Division of Pediatric Cardiology, Taipei Veterans General Hospital
| | - Cheng-Hung Li
- Division of Cardiology, Taipei Veterans General Hospital
- Department of Medicine and Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University School of Medicine
| | - Tze-Fan Chao
- Division of Cardiology, Taipei Veterans General Hospital
- Department of Medicine and Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University School of Medicine
| | | | - Yung-Kuo Lin
- Division of Cardiology, Taipei Wan Fang Hospital
| | - Chern-En Chiang
- Division of Cardiology, Taipei Veterans General Hospital
- Department of Medicine and Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University School of Medicine
| | - Shih-Ann Chen
- Division of Cardiology, Taipei Veterans General Hospital
- Department of Medicine and Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University School of Medicine
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Atrioventricular node anatomy and physiology: implications for ablation of atrioventricular nodal reentrant tachycardia. Curr Opin Cardiol 2009; 24:105-12. [DOI: 10.1097/hco.0b013e328323d83f] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Hwang HK, Wolff GS, Sun FJ, Young ML. The most common site of success and its predictors in radiofrequency catheter ablation of the slow atrioventricular nodal pathway in children. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2008; 31:1300-6. [PMID: 18811811 DOI: 10.1111/j.1540-8159.2008.01181.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Locating ablation targets on the slow pathway in children as one would in adults may not accommodate the dimensional changes of Koch's triangle that occur with heart growth. We investigated the most common site of success and the effect of a variety of variables on the outcome of slow pathway ablation in children. METHODS A total of 116 patients (ages 4-16 years) with structurally normal hearts underwent radiofrequency ablation of either the antegrade or the retrograde slow pathway. Ablation sites were divided into eight regions (A1, A2, M1, M2, P1, P2, CS1, and CS2) at the septal tricuspid annulus. RESULTS Ablation was successful in 112 (97%) children. The most common successful ablation sites were at the P1 region. The less the patient weighed, the more posteriorly the successful site was located (P = 0.023, OR 0.970, 95% CI 0.946-0.996), and the more likely the slow pathway was eliminated rather than modified: median weight was 46.7 kg (range, 14.5-94.3 kg) in the eliminated group and 56.5 kg (range, 20-82.6 kg) in the modified group (P = 0.021, OR 1.039, 95% CI 1.006-1.073). CONCLUSIONS The most common site of success for slow pathway ablation in children is at the P1 region of the tricuspid annulus. The successful sites in lighter children are more posteriorly located. Weight is also a predictor of whether the slow pathway is eliminated or only modified.
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Affiliation(s)
- Haw-Kwei Hwang
- Department of Pediatrics, Mackay Memorial Hospital, Taipei, Taiwan
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29
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HU YUFENG, TAI CHINGTAI, LIN YENNJIANG, CHANG SHIHLIN, LO LIWEI, WONGCHAROEN WANWARANG, UDYAVAR AMEYAR, TUAN TACHUAN, CHEN SHIHANN. Does the Age Affect the Fluoroscopy-Guided Transseptal Puncture in Catheter Ablation of Atrial Fibrillation? PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2007; 30:1506-10. [DOI: 10.1111/j.1540-8159.2007.00899.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Tanaka Y, Yamabe H, Morihisa K, Uemura T, Kawano H, Nagayoshi Y, Kojima S, Ogawa H. Incidence and Mechanism of Dislocated Fast Pathway in Various Forms of Atrioventricular Nodal Reentrant Tachycardia. Circ J 2007; 71:1099-106. [PMID: 17587718 DOI: 10.1253/circj.71.1099] [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: 11/09/2022]
Abstract
BACKGROUND The incidence and mechanism of the dislocated antegrade fast pathway (A-FP) were examined in various forms of atrioventricular nodal reentrant tachycardia (AVNRT). METHODS AND RESULTS To localize the A-FP, 5 atrial sites comprising the inferior coronary sinus ostium (CSOS), apex of the triangle of Koch (A-TOK), and 3 equidistant sites on the atrioventricular junction extending from A-TOK to CSOS (site S, M, and I) were pace mapped at 100 beats/min in 71 patients with slow-fast (n=49), fast-slow (n=7) and slow-intermediate (n=15) forms of AVNRT. The site with the shortest interval between the stimulus and His potential recorded at the A-TOK (shortest St-H) was defined as the A-FP site. The A-FP was located at A-TOK in 31 patients (nondislocated group), and inferior to A-TOK in 40 patients (site S in 26, M in 13, and I in one patient; dislocated group). There was no significant difference in the location of the A-FP among the 3 forms of AVNRT. Although the shortest St-H did not differ between groups, the St-H at A-TOK in the dislocated group was significantly longer than that in the nondislocated group. Additionally, the His potential preceding that of the A-TOK was observed more frequently inferior to the A-TOK in the dislocated group than in the nondislocated group, suggesting that the A-FP dislocation was accompanied by displacement of the His bundle. CONCLUSIONS Dislocated A-FP was frequently and uniformly observed among various forms of AVNRT, and is probably caused by inferior displacement of the entire atrioventricular node - His bundle apparatus.
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Affiliation(s)
- Yasuaki Tanaka
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
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31
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Fish FA. Step Away from the Jump: Sustained Slow Conduction in Pediatric Atrioventricular Nodal Reentrant Tachycardia. J Cardiovasc Electrophysiol 2006; 17:645-7. [PMID: 16836715 DOI: 10.1111/j.1540-8167.2006.00490.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Geller JC, Biblo LA, Carlson MD. Relation Between the AH Interval and the Ablation Site in Patients with Atrioventricular Nodal Reentrant Tachycardia. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2004; 27:1347-54. [PMID: 15511243 DOI: 10.1111/j.1540-8159.2004.00638.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
The determinants of slow pathway conduction in patients with AV nodal reentrant tachycardia (AVNRT) are still unknown, and great differences in the AH interval during slow pathway conduction are observed between patients. In 35 patients with typical AVNRT who underwent successful slow pathway ablation (defined as complete elimination of dual pathway physiology), the A2H2 interval at the "jump" during programmed atrial stimulation and the AH interval during AVNRT (as a reflection of slow pathway conduction time) and the fluoroscopic distance between the successful ablation site and the His-bundle recording site and between the coronary sinus ostium (CSO) and the His-bundle recording site were determined. The mean (+/- SEM) AH interval during slow pathway conduction was 323 +/- 12 ms with programmed stimulation and 310 +/- 10 ms during AVNRT. The mean number of energy applications was 8 +/- 1 (range 1-21). The mean distances between (1) the successful ablation site and the His bundle recording site and (2) between the CSO and the His-bundle recording site were 24 +/- 1 and 28 +/- 1 mm in the RAO and 23 +/- 1 and 28 +/- 1 mm in the LAO projections, respectively. The AH interval during slow pathway conduction correlated significantly with the distance between the successful ablation site and the His-bundle (P < 0.001) but not with the distance between CSO and His-bundle recording site. There is a significant correlation between the AH interval during slow pathway conduction and the distance of the successful ablation site from the His bundle. This relationship (1) suggests that, in addition to functional factors, anatomic factors influence slow pathway conduction and (2) may be helpful in determining the initial energy application site during slow pathway ablation.
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Affiliation(s)
- J Christoph Geller
- Division of Cardiology, University Hospitals of Cleveland, Case Western Reserve University, Cleveland, Ohio 44106, USA
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Pecht B, Maginot KR, Boramanand NK, Perry JC. Techniques to avoid atrioventricular block during radiofrequency catheter ablation of septal tachycardia substrates in young patients. J Interv Card Electrophysiol 2002; 7:83-8. [PMID: 12391424 DOI: 10.1023/a:1020828401929] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
UNLABELLED Radiofrequency catheter ablation (RFCA) has proven safe for most young patients, but the risk of inadvertent atrioventricular (AV) block remains. The purpose of this report is to describe techniques to avoid inadvertent AV block during effective RFCA in young patients with septal tachycardia substrates. METHODS The techniques included intubation and apnea during RFCA, coronary sinus pacing during RFCA to observe intact AV conduction during junctional ectopy, localizing the optimal His electrogram prior to RFCA, not ablating during tachycardia and titrating power output with temperature monitoring. RESULTS In the period January 1995-June 2001, RFCA of 424 tachycardia substrates was performed. A total of 217 consecutive septal tachycardia substrates are included in this report. Apnea eliminated a mean catheter tip displacement of 5.4 +/- 2.5 mm seen during respiration. No patient experienced transient or permanent complete AV block after any of the 217 substrate ablation procedures. All of the patients had normal PR intervals following ablation without development of any degree of AV block in 194 patients at latest follow-up. RFCA success for substrates with septal accessory pathways was 87/96 (91%), permanent junctional reciprocating tachycardia (PJRT) 15/16 (94%), typical atrioventricular node reentry tachycardia (AVNRT) 82/85 (96%), atypical AVNRT 6/7 (86%) and intra-atrial reentry tachycardia (IART) 10/13 (77%). Fluoroscopy time averaged 10.8 minutes. For patients with accessory pathway, 8 (7.9%) developed a recurrence. CONCLUSION Catheter stability is paramount to safe and effective RFCA in septal locations. Use of these techniques resulted in acceptable success rates and low recurrence rate for RFCA of septal tachycardia substrates while avoiding inadvertent AV block in these young patients.
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Affiliation(s)
- Benjamin Pecht
- Division of Cardiology, Children's Specialists, Children's Hospital San Diego, Department of Pediatrics, University of California, San Diego, California 92123, USA
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Batra R, Nair M, Kumar M, Mohan J, Shah P, Kaul U, Arora R. Intracardiac echocardiography guided radiofrequency catheter ablation of the slow pathway in atrioventricular nodal reentrant tachycardia. J Interv Card Electrophysiol 2002; 6:43-9. [PMID: 11839882 DOI: 10.1023/a:1014124206594] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND ICE has demonstrated its utility in imaging right atrial structures but its utility in slow pathway (SP) ablation has not been documented in a randomized trial. METHODS The feasibility of using ICE as a imaging modality to identify the effective site of SP ablation was done in part one of the study comprising 10 patients of typical AVNRT. Subsequently, a prospective randomized study was done comparing the conventional (group A) and ICE guided (group B) ablation of the SP. Each group had 20 patients of typical AVNRT. Ablation in the conventional arm was guided by intracardiac electrograms and fluoroscopy. Group B patients underwent SP ablation guided primarily by ICE imaging; fluoroscopy was used mainly for initial placement of catheters. RESULTS Reliable & stable ICE images were obtained in all patients. Part I of the study showed that RF pulses given when the ablation catheter was seen to cross the atrioventricular muscular septum (AVMS), always resulted in junctional rhythm. In Group B, RF pulse was delivered only when the ablation catheter was at the AVMS making an obtuse angle with the image of the His-bundle catheter. Consistent junctional rhythm and abolition of SP resulted at this site. Compared to group A, patients in group B required fewer pulses (mean 1.4 +/- 0.6 vs. 4.4 +/- 3.0; p < 0.05, median 1 vs. 5; p < 0.01), achieved a higher temperature (56 +/- 4 degrees C vs. 50 +/- 6 degrees C) and had more frequent junctional rhythm (100% vs. 70%) during RF pulse. CONCLUSIONS A critical portion of SP exists adjacent to Tricuspid valve overlying the AVMS. ICE imaging consistently and reliably localizes this site and RF applications here result in interruption of antegrade SP conduction.
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Affiliation(s)
- Ravinder Batra
- Department of Cardiology, GB Pant Hospital, JLN Marg, University of Delhi, New Delhi-10002, India
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Heidbüchel H, Willems R, van Rensburg H, Adams J, Ector H, Van de Werf F. Right atrial angiographic evaluation of the posterior isthmus: relevance for ablation of typical atrial flutter. Circulation 2000; 101:2178-84. [PMID: 10801759 DOI: 10.1161/01.cir.101.18.2178] [Citation(s) in RCA: 93] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Gaining anatomic information about the posterior isthmus is not generally part of flutter ablation procedures. We postulated that right atrial (RA) angiography could rationalize the ablation approach by revealing the conformation of the isthmus. METHODS AND RESULTS In 100 consecutive patients, biplane RA angiography was performed before ablation to guide catheter contact with the isthmus along its length. Angiography showed a wide variation in the width of the isthmus (17 to 54 mm; 31.3+/-7.9), its angle with the inferior vena cava in the right anterior oblique projection (68 degrees to 114 degrees; 90.3+/-9.0 degrees ), and its lateral position relative to the inferior vena cava in the left anterior oblique projection. A deep sub-Eustachian recess was revealed in 47%, with a mean depth of 4.3+/-2.1 mm (1.5 to 9.4). A Eustachian valve was visualized in 24%. Ablation resulted in bidirectional conduction block (which could be transient) in all, with a median of 2 dragging radiofrequency (RF) applications (2.3+/-2.5 RF applications; 57 degrees C, < or =99 seconds each). Permanent block was achieved in 99%, with a median of 3 RF applications (3.4+/-3.0). The presence of a Eustachian valve or concave isthmus was associated with statistically more RF applications; the same trend was seen for patients with deep pouches. The number of RF applications decreased statistically throughout the study, indicating a learning curve. No patient had a recurrence after a follow-up of 13+/-11 months. CONCLUSIONS Right atrial angiography reveals a highly variable isthmus anatomy, often showing particular configurations that can make ablation more laborious. Rational adaptation of the ablation approach to these anatomic findings may contribute to successful ablation.
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Affiliation(s)
- H Heidbüchel
- Department of Cardiology, University Hospital Gasthuisberg, University of Leuven, Belgium.
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Poret P, Leclercq C, Gras D, Mansour H, Fauchier L, Daubert C, Mabo P. Junctional rhythm during slow pathway radiofrequency ablation in patients with atrioventricular nodal reentrant tachycardia: beat-to-beat analysis and its prognostic value in relation to electrophysiologic and anatomic parameters. J Cardiovasc Electrophysiol 2000; 11:405-12. [PMID: 10809493 DOI: 10.1111/j.1540-8167.2000.tb00335.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Junctional rhythm usually is considered a sensitive but nonspecific marker of successful ablation of the slow pathway in AV nodal reentrant tachycardia. Nevertheless, this junctional rhythm has been little studied, and its relations to recognized predictors of successful radiofrequency (RF) application were never established in any study. METHODS AND RESULTS Thirty-nine patients underwent RF ablation of the slow pathway for AV nodal reentrant tachycardia. Ninety RF applications were delivered, and each ablation site was determined using three different fluoroscopic projections. Six anatomic zones were defined from low posterior septum to the site of distal His-bundle recording (P1, P2, M1, M2, A1, and A2). Characteristics of junctional rhythm during RF applications were analyzed. Atrial electrogram characteristics at the ablation sites also were studied. All patients had successful slow pathway ablation, without any complication. The ablation sites were located as follows: 41 at P1, 26 at P2, 20 at M1, and 3 in M2. Forty RF applications were successful: 14 of 41 attempts at P1, 7 of 26 at P2, 16 of 20 at M1, and 3 of 3 at M2. Mid-septal ablation site (M1 and M2) was associated with higher occurrence of junctional rhythm (P < 0.0001), earlier first junctional beat (P = 0.008), and earlier occurrence of the longest junctional burst (P = 0.03) compared with posterior ablation site (P1 and P2). The combination of a mid-septal ablation site and a first junctional beat occurring < or = 3 seconds after onset of RF application identified successful RF application with 100% accuracy. Using multivariate analysis, the ablation site, duration of atrial electrogram (including slow pathway potential when present), and occurrence of junctional rhythm were independent predictors of success. CONCLUSION Successful slow pathway ablation depends on many factors. Junctional rhythm characteristics are related to the site of RF delivery and can be helpful in assessing successful slow pathway ablation.
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Affiliation(s)
- P Poret
- Department of Cardiology, CHU Pontchaillou, Rennes, France
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WEISMÜLLER PETER, OBERGASSEL LUDGER, KATTENBECK KLAUS, LIS WLADISLAW, TRAPPE HANSJOACHIM. Need for Fast Pathway Ablation in Typical Irregular AV Nodal Reentrant Tachycardia in a Patient with Multiple AV Nodal Pathways. J Interv Cardiol 2000. [DOI: 10.1111/j.1540-8183.2000.tb00278.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Abstract
INTRODUCTION There is growing use of the Todaro tendon and triangle of Koch as anatomic icons for invasive cardiac electrophysiologists. Reasons exist to doubt this validity. METHODS AND RESULTS Histologic sections were prepared from 96 anatomically normal human hearts. The study area extended from the crista supraventricularis to the eustachian valve and included the AV node and His bundle. This encompasses any tendon of Todaro. Because the purported triangle of Koch includes the tendon of Todaro, all of Koch's available publications were examined. The tendon of Todaro is absent in only one fourth of infant hearts, but in two thirds of adult hearts. Tendons present were less often single than double or more, rarely exceeded 4 mm in length, and were seldom > 1 mm in diameter. Tendons usually originated from the central fibrous body and ended in the eustachian valve. Their origin most often was over the His bundle or its junction with the AV node, rather than the AV node. Tendons were primarily composed of collagen. Koch never described any triangle or acknowledged existence of tendons of Todaro. CONCLUSION Todaro tendons are too often absent (or multiple) to warrant use as anatomic landmarks. Without this side of the supposed triangle of Koch, the entire tendon and triangle concept collapses and should be abandoned. There are numerous far more constant anatomic landmarks available to orient one to the human AV node and His bundle; these are briefly reviewed.
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Affiliation(s)
- T N James
- Department of Medicine, University of Texas Medical Branch, Galveston 77555-0175, USA
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Weiss C, Cappato R, Willems S, Meinertz T, Kuck KH. Prospective evaluation of the coronary sinus anatomy in patients undergoing electrophysiologic study. Clin Cardiol 1999; 22:537-43. [PMID: 10492844 PMCID: PMC6655875 DOI: 10.1002/clc.4960220810] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/1998] [Accepted: 01/15/1999] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Previous retrospective studies could find a predominant incidence of coronary sinus (CS) anomalies in patients with accessory pathways and a characteristic anatomy of the CS ostium in patients with atrioventricular nodal reentrant tachycardias (AVNRT). HYPOTHESIS In the present prospective study, CS angiograms were prospectively performed to analyze the incidence of CS anomalies and to measure the diameters of the CS ostium. METHODS The study included patients referred for electrophysiologic study and catheter ablation of various tachyarrhythmias. The anatomy of the CS and its side branches was visualized [left anterior oblique (LAO) 30 degrees, right anterior oblique (RAO) 30 degrees] by retrograde angiography in 204 consecutive patients (82 women, 122 men, age 45 +/- 15 years); of these, 120 presented with 123 accessory pathways (45 left-sided, 33 right-sided, 45 septal). The diagnosis in the remaining patients was atrioventricular nodal reentrant tachycardia in 43 cases, atrial tachycardia or atrial fibrillation in 12, and ventricular tachycardia in 15. In 14 patients, the indication for the electrophysiologic study was an unexplained syncope. The CS angiogram was evaluated for anomalies and the size of the CS ostium was manually measured in both projections. RESULTS Anomalies of the CS defined as diverticula, persistent left superior vena cava, or enlarged CS ostia were found in 18 patients (9%). Of those, CS diverticula were found in nine patients, all with a posteroseptal or left posterior manifest accessory pathway, which was abolished within the neck of the diverticulum in seven patients and at the posteroseptal tricuspid annulus in two patients. Persistence of the left superior vena cava was found in five patients, four had atrioventricular reentrant tachycardia secondary to five accessory pathways (left free wall in four, right midseptal in one), and one patient had atrioventricular nodal reentrant tachycardia (AVNRT). Enlargement of the CS ostium of > 25 mm width was detected in nine patients (5%), of whom four had AVNRT. However, the width of the CS ostium generally did not differ significantly between patients with AVNRT (LAO: 14.4 +/- 5.6; RAO 9.3 +/- 2.4 mm) compared with the control group (LAO 13.4 +/- 4.1; 8.2 +/- 1.9 mm). CONCLUSIONS Anomalies of the CS as diverticula, persistent superior vena cava, or enlargement of the CS ostium are predominantly found in patients with accessory pathway-related tachycardias. Diverticula of the proximal CS were found in 7% of patients with accessory pathways; in these cases, ablation succeeded mostly by radiofrequency (RF) current delivery in the neck of the diverticulum. Enlargement of the CS ostium was more often seen in patients with AVNRT than in all other patients. However, in general the measurements of the coronary sinus ostium did not significantly differ in patients with AVNRT compared with the control group.
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MESH Headings
- Adult
- Atrial Fibrillation/diagnosis
- Atrial Fibrillation/physiopathology
- Atrial Fibrillation/therapy
- Catheter Ablation
- Coronary Angiography
- Coronary Vessel Anomalies/physiopathology
- Electrophysiology
- Female
- Heart Conduction System/physiopathology
- Humans
- Male
- Middle Aged
- Prospective Studies
- Tachycardia, Atrioventricular Nodal Reentry/diagnosis
- Tachycardia, Atrioventricular Nodal Reentry/physiopathology
- Tachycardia, Atrioventricular Nodal Reentry/therapy
- Tachycardia, Ectopic Atrial/diagnosis
- Tachycardia, Ectopic Atrial/physiopathology
- Tachycardia, Ectopic Atrial/therapy
- Tachycardia, Ventricular/diagnosis
- Tachycardia, Ventricular/physiopathology
- Tachycardia, Ventricular/therapy
- Vena Cava, Superior/abnormalities
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Affiliation(s)
- C Weiss
- Department of Cardiology University Hospital Eppendorf, Germany
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Yamane T, Iesaka Y, Goya M, Takahashi A, Fujiwara H, Hiraoka M. Optimal target site for slow AV nodal pathway ablation: possibility of predetermined focal mapping approach using anatomic reference in the Koch's triangle. J Cardiovasc Electrophysiol 1999; 10:529-37. [PMID: 10355694 DOI: 10.1111/j.1540-8167.1999.tb00709.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Although a variety of ablation techniques have been developed in the treatment of atrioventricular nodal reentrant tachycardia (AVNRT), there have been few reports discussing the location of the optimal target site. Based on our early experiences, we hypothesized that radiofrequency (RF) current applied around the upper margin of the coronary sinus ostium (UCSO) results in the most effective and safe treatment of AVNRT. METHODS AND RESULTS To confirm our hypothesis, the efficacy of RF currents applied around the UCSO guided by local electrograms in 59 patients (group B: predetermined focal mapping approach) were compared with the outcomes in 60 other patients previously treated with the standard electrogram-guided mapping method starting around the lower margin of the coronary sinus ostium (group A). The precise location of ablation catheters at successful sites (S) was also evaluated. All the patients were successfully treated without complications. Significantly fewer RF pulses and lower energies were needed in group B patients (mean RF applications: 4.3 vs 1.4 applications, mean total energy delivered: 4,699 vs 2,236 J in groups A and B, respectively, P < 0.01). Detailed analyses of the anatomical locations of S using CS venography in group B patients who received only a single RF application (46 patients) revealed that the distance between His and S varied according to the length of Koch's triangle, while that between S and UCSO was relatively constant. In 85 % of these 46 patients, S was located within 5 mm above and below the level of the UCSO. CONCLUSION RF applications around the UCSO guided by local electrograms yielded excellent outcomes in AVNRT patients with wide varieties in the size of Koch's triangle. The optimal target site was located within 5 mm above and below the level of UCSO along the tricuspid annulus.
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Affiliation(s)
- T Yamane
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Ibaraki, Japan
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41
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Fujii E, Kasai A, Omichi C, Teramura S, Yasuda M, Uchida F, Nakano T. Electrophysiological characteristics during slow pathway ablation of posterior atrioventricular junctional reentrant tachycardia. Pacing Clin Electrophysiol 1998; 21:2510-6. [PMID: 9825376 DOI: 10.1111/j.1540-8159.1998.tb01210.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The purpose of this study was to compare the electrophysiological characteristics of posterior and anterior atrioventricular junctional reentrant tachycardia (AVJRT) during radiofrequency (RF) catheter ablation of a slow pathway. Twenty-four patients with common AVJRT, including 4 posterior (P) and 20 anterior AVJRT (A) were studied. We analyzed the retrograde atrial activation sequence of junctional rhythm and the presence of transient HA block during slow pathway ablation. When HA block developed, the AH interval before ablation and immediately after the end of energy delivery was measured. Successful ablation sites were divided into three groups; high (H), middle (M), and low (L) from the His bundle to the floor of the coronary sinus orifice. The results were: (1) the number of successful ablation sites were H 0, M 1, L 3 in P and H 1, M 8, L 11 in A; (2) the HA interval during AVJRT in P was longer than that in A (109 +/- 48 ms vs 43 +/- 6 ms, P < 0.01); (3) the retrograde atrial activation sequence during junctional rhythm was strictly concordant with that during AVJRT in both groups, but HA block developed during slow pathway ablation more often in P than in A (100% vs 30%, P < 0.01); and (4) The AH interval did not lengthen after HA block developed in P. These data suggest that another pathway does exist from the AV node to the atrium in addition to anterograde fast pathway and slow pathway, and that this pathway is used as the retrograde limb of P.
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Affiliation(s)
- E Fujii
- Department of Internal Medicine, Matsusaka City Hospital, Japan.
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42
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Geller JC, Biblo LA, Carlson MD. New evidence that AV node slow pathway conduction directly influences fast pathway function. J Cardiovasc Electrophysiol 1998; 9:1026-35. [PMID: 9817554 DOI: 10.1111/j.1540-8167.1998.tb00880.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Shortening of the AV node fast pathway effective refractory period (ERP) following successful slow pathway ablation may be a nonspecific effect of energy application at the AV junction or may be due to elimination of a direct effect of slow pathway conduction on the fast pathway. METHODS AND RESULTS Twenty-six consecutive patients (20 women and 6 men; mean age 45 +/- 3 years) with typical AV nodal reentrant tachycardia who underwent successful slow pathway ablation (defined as complete elimination of dual AV node physiology) were studied. The fast pathway ERP (at a drive train cycle length of 600 msec) was determined prior to ablation (baseline) and following unsuccessful and successful ablation attempts. Successful slow pathway ablation shortened the fast pathway ERP significantly (317 +/- 9 msec; P < 0.001) compared to baseline (386 +/- 12 msec), whereas unsuccessful ablations had no effect (376 +/- 11 msec). Sinus cycle length, the AH interval, and blood pressure were unchanged following successful ablation. Shortening of the fast pathway ERP did not correlate with the number of energy applications or with two measures of the proximity between the slow and the fast pathway. CONCLUSION These results support the hypothesis that shortening of the fast pathway ERP following slow pathway ablation is due to elimination of a direct effect of slow pathway conduction on fast pathway function rather than a nonspecific effect of repeated energy delivery at the AV junction.
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Affiliation(s)
- J C Geller
- Division of Cardiology, University Hospitals of Cleveland, and the Cardiac Bioelectricity Research and Training Center, Case Western Reserve University Medical School, Ohio 44106, USA
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43
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Inoue S, Becker AE. Koch's triangle sized up: anatomical landmarks in perspective of catheter ablation procedures. Pacing Clin Electrophysiol 1998; 21:1553-8. [PMID: 9725153 DOI: 10.1111/j.1540-8159.1998.tb00242.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Koch's triangle contains the compact part of the atrioventricular node and is anatomically delineated by the Eustachian ridge, the membranous septum, and the insertion of the tricuspid valve. Inferiorly, Koch's triangle ends at the site of the os of the coronary sinus and, in part, is continuous with the sub-Eustachian pouch. Catheter ablation procedures for several types of reentrant tachycardias are based on identifying these anatomical landmarks. Variability in the dimensions of Koch's triangle thus may be clinically relevant. We examined 50 hearts. Anatomical landmarks measured were the Eustachian ridge, the tricuspid valve, the overall length between the membranous septum and the coronary sinus, the width of the coronary sinus, the Eustachian ridge in its roof and the distance to the tricuspid valve, and that of the sub-Eustachian pouch. Individual variations were marked. The mean values (+/- SD) were: Eustachian ridge 29.4 +/- 5.3 mm, tricuspid valve 28.9 +/- 4.5 mm, coronary sinus 10.8 +/- 2.2 mm, Eustachian ridge 3.7 +/- 2.3 mm, space underneath coronary sinus 8.6 +/- 3.4 mm, and sub-Eustachian pouch 26.8 +/- 3.3 mm. The overall length varied between 15 and 38 mm, with a mean of 26.3 +/- 4.5. In conclusion, Koch's triangle shows considerable individual variations in size. Given the fact that the absolute figures for the range in size of the compact atrioventricular node is much less than that of Koch's triangle, these variations have implications for catheter ablation procedures.
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Affiliation(s)
- S Inoue
- Department of Cardiovascular Pathology, Academic Medical Center, University of Amsterdam, The Netherlands
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44
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Francalanci P, Drago F, Agostino DA, Di Liso G, Di Ciommo V, Boldrini R, Ragonese P, Bosman C. Koch's triangle in pediatric age: correlation with extra- and intracardiac parameters. Pacing Clin Electrophysiol 1998; 21:1576-9. [PMID: 9725156 DOI: 10.1111/j.1540-8159.1998.tb00245.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
The atrioventricular node is situated in the lower atrial septum, at the apex of the Koch's triangle. The dimensions of the Koch's triangle are studied in adult humans, while no data exist about them in pediatric age. The knowledge of the dimensions of Koch's triangle in childhood is very important for safe and correct application of radiofrequency energy during transcatheter ablation. The dimensions of Koch's triangle were determined in 69 human pediatric hearts. The median age of the children was 3 months, with a range from 1 day to 14 years, 30 were female and 39 were male. Relations between body weight (extracardiac parameter) and tricuspid valve diameter (intracardiac parameter) were determined in all hearts to show morphometric modifications with growth. The distribution of body weight was not Gaussian and no correlation could be obtained between Koch's triangle dimensions and body weight. However, it was possible to identify that the mean ratio between the cathetus of the Koch's triangle corresponding to the annulus of the tricuspid valve and the tricuspid valve diameter was 0.45 +/- 0.16, with a highly significant correlation coefficient (r = 0.653, P < 0.001). Therefore, by knowing: (1) the diameter of the tricuspid valve, and (2) the constant ratio between the cathetus of the Koch's triangle and the tricuspid valve diameter, it is possible to calculate the length of the segment of the tricuspid annulus along which the transcatheter application of radiofrequency current can be applied to ablate the slow-pathway, thus reducing the risks of damage of the atrioventricular node.
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Affiliation(s)
- P Francalanci
- Department of Pathology, Bambino Gesù Hospital, Rome, Italy.
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Inoue S, Becker AE. Posterior extensions of the human compact atrioventricular node: a neglected anatomic feature of potential clinical significance. Circulation 1998; 97:188-93. [PMID: 9445172 DOI: 10.1161/01.cir.97.2.188] [Citation(s) in RCA: 169] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Catheter ablation procedures have revived interest in the detailed anatomy of the specialized atrioventricular (AV) septal junctional area. The compact AV node usually is considered to have a blunt posterior end. The objective of this study was to reconstruct the human compact AV node in relation to the landmarks of Koch's triangle, with emphasis on its posterior extension. METHODS AND RESULTS In 21 hearts obtained from autopsies, the AV nodal septal junctional area was removed en bloc, serially sectioned, and reconstructed. None of the hearts showed a blunt posterior ending of the compact AV node; 13 showed posterior extensions on both the right and left sides; 7 had a rightward posterior extension only; and 1 heart showed a single leftward extension. Hence, a rightward posterior extension was present in 20 of 21 hearts. Furthermore, in 16 of these 20 hearts, the rightward extension continued to the level of the coronary sinus ostium; in 7, the bundle extended beyond this anatomic landmark. The mean length of the right posterior extension was 4.4+/-2.0 mm; that of the leftward posterior extension was 1.8+/-0.9 mm. Superimposed onto the slope of the muscular AV septum, viewed from the right atrium, the rightward extension ran close to the tricuspid annulus with the leftward extension positioned superiorly. CONCLUSIONS The human compact AV node contains rightward and leftward posterior extensions, with the right extension close to the tricuspid annulus. It is tempting to speculate that these extensions are involved in "slow pathway" conduction.
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Affiliation(s)
- S Inoue
- Department of Cardiovascular Pathology, Academic Medical Center, University of Amsterdam, The Netherlands
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