1
|
Park S, Park JW, Kim S, Kim H, Kim SH, Oh YS, Choi Y. Upper common pathway analysis using late atrial premature depolarization in atrioventricular nodal reentry tachycardia. Heart Rhythm 2024; 21:1729-1734. [PMID: 38552730 DOI: 10.1016/j.hrthm.2024.03.1788] [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: 02/13/2024] [Revised: 03/21/2024] [Accepted: 03/25/2024] [Indexed: 04/18/2024]
Abstract
BACKGROUND Anatomic and electrophysiologic findings suggest that the actual circuit of atrioventricular nodal reentrant tachycardia (AVNRT) involves the perinodal atrium. However, occasional instances in which the atrium is dissociated from the AVNRT have led to the concept of an upper common pathway (UCP). OBJECTIVE We aimed to assess the prevalence of UCP in AVNRT using a late atrial premature depolarization (LAPD) maneuver. METHODS Patients who were diagnosed with typical AVNRT by electrophysiologic studies were enrolled. For evaluation of the presence of UCP, an LAPD was given at the coronary sinus ostium (osCS) during AVNRT, and then pacing was repeated incrementally every 10 ms. Electrograms in the earliest retrograde atrial activation site (ERAS) near the proximal His were mapped and recorded during the pacing. Results were interpreted as follows: absence of UCP-an LAPD from the osCS can reset the tachycardia without depolarizing the ERAS; presence of UCP-an LAPD from the osCS can depolarize the ERAS without resetting the tachycardia; and indeterminate-an LAPD from the osCS either resets the ERAS and tachycardia simultaneously or does not reset both. RESULTS The LAPD maneuver was performed in 126 patients with AVNRT. It demonstrated an absence of UCP in 121 (96.0%) patients and the presence of UCP in 3 (2.4%) patients; the result was indeterminate in 2 (1.6%) patients. CONCLUSION The LAPD maneuver revealed that the presence of UCP is indicated in only rare cases of AVNRT. In most AVNRT cases, the atrium is involved in the reentry circuit.
Collapse
Affiliation(s)
- Soyoon Park
- Division of Cardiology, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Cardiovascular Research Institute for Intractable Disease, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jeong-Wook Park
- Division of Cardiology, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Soohyun Kim
- Division of Cardiology, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Cardiovascular Research Institute for Intractable Disease, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hwajung Kim
- Cardiovascular Research Institute for Intractable Disease, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Division of Cardiology, Department of Internal Medicine, Yeouido St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sung-Hwan Kim
- Division of Cardiology, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Cardiovascular Research Institute for Intractable Disease, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yong-Seog Oh
- Division of Cardiology, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Cardiovascular Research Institute for Intractable Disease, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Young Choi
- Division of Cardiology, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Cardiovascular Research Institute for Intractable Disease, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| |
Collapse
|
2
|
Hachiya H, Kusa S, Hara S, Ishizawa T, Hirano H, Nakata T, Doi J, Sato Y, Miwa N. A slightly irregular SVT: What is the mechanism? Pacing Clin Electrophysiol 2024; 47:902-904. [PMID: 38967998 DOI: 10.1111/pace.15025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 05/16/2024] [Accepted: 05/27/2024] [Indexed: 07/07/2024]
Affiliation(s)
- Hitoshi Hachiya
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki, Japan
| | - Shigeki Kusa
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki, Japan
| | - Satoshi Hara
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki, Japan
| | - Taiki Ishizawa
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki, Japan
| | - Hidenori Hirano
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki, Japan
| | - Tadanori Nakata
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki, Japan
| | - Junichi Doi
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki, Japan
| | - Yoshikazu Sato
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki, Japan
| | - Naoyuki Miwa
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki, Japan
| |
Collapse
|
3
|
Wakamatsu Y, Nagashima K, Watanabe R, Hirata S, Hirata M, Okumura Y. Beyond the lens: Unveiling the invisible atrioventricular node in the era of high-density mapping. J Cardiol 2024:S0914-5087(24)00099-6. [PMID: 38834137 DOI: 10.1016/j.jjcc.2024.05.010] [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: 01/10/2024] [Revised: 05/21/2024] [Accepted: 05/29/2024] [Indexed: 06/06/2024]
Abstract
Numerous studies have clarified the histological characteristics of the area surrounding the atrioventricular (AV) node, commonly referred to as the triangle of Koch (ToK). Although it is suggested that the conduction of electric impulses from the atria to the ventricles via the AV node involves myocytes possessing distinct conduction properties and gap junction proteins, a comprehensive understanding of this complex conduction has not been fully established. Moreover, although various pathways have been proposed for both anterograde and retrograde conduction during atrioventricular nodal reentrant tachycardia (AVNRT), the reentrant circuits of AVNRT are not fully elucidated. Therefore, the slow pathway ablation for AVNRT has been conventionally performed, targeting both its anatomical location and slow pathway potential obtained during sinus rhythm. Recently, advancements in high-density three-dimensional (3D) mapping systems have facilitated the acquisition of more detailed electrophysiological potentials within the ToK. Several studies have indicated that the activation pattern, the low-voltage area within the ToK obtained during sinus rhythm, and the fractionated potentials acquired during tachycardia may be optimal targets for slow pathway ablation. This review provides an overview of the tissue surrounding the AV node as reported to date and summarizes the current understanding of AV conduction and AVNRT circuits. Furthermore, we discuss recent findings on slow pathway ablation utilizing high-density 3D mapping systems, exploring strategies for optimal slow pathway ablation.
Collapse
Affiliation(s)
- Yuji Wakamatsu
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Koichi Nagashima
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan.
| | - Ryuta Watanabe
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Shu Hirata
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Moyuru Hirata
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| |
Collapse
|
4
|
Miyazaki S, Kinjo T. The response of supraventricular tachycardia to adenosine: What is the mechanism? J Cardiovasc Electrophysiol 2023; 34:1485-1487. [PMID: 37178256 DOI: 10.1111/jce.15928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 04/24/2023] [Accepted: 04/29/2023] [Indexed: 05/15/2023]
Affiliation(s)
- Shinsuke Miyazaki
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tsunemichi Kinjo
- Department of Cardiology, Hokushin General Hospital, Nagano, Japan
| |
Collapse
|
5
|
Hadid C, Celano L, Di Toro D, Antezana-Chavez E, Gallino S, Iralde G, Calvo D, Ávila P, Atea L, Gonzalez S, Maldonado S, Labadet C. Variability of the VA interval at tachycardia induction: a simple method to differentiate orthodromic reciprocating tachycardia from atypical atrioventricular nodal reentrant tachycardia. J Interv Card Electrophysiol 2022; 66:637-645. [PMID: 36152135 DOI: 10.1007/s10840-022-01376-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Accepted: 09/13/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND The differential diagnosis between orthodromic atrioventricular reentry tachycardia (AVRT) and atypical AV nodal reentrant tachycardia (aAVNRT) is sometimes challenging. We hypothesize that aAVNRTs have more variability in the retrograde conduction time at tachycardia onset than AVRTs. METHODS We aimed to assess the variability in retrograde conduction time at tachycardia onset in AVRT and aAVNRT and to propose a new diagnostic tool to differentiate these two arrhythmia mechanisms. We measured the VA interval of the first beats after tachycardia induction until it stabilized. The difference between the maximum and minimum VA intervals (∆VA) and the number of beats needed for the VA interval to stabilize was analyzed. Atrial tachycardias were excluded. RESULTS A total of 107 patients with aAVNRT (n = 37) or AVRT (n = 64) were included. Six additional patients with decremental accessory pathway-mediated tachycardia (DAPT) were analyzed separately. All aAVNRTs had VA interval variability. The median ∆VA was 0 (0 - 5) ms in AVRTs vs 40 (21 - 55) ms in aAVNRTs (p < 0.001). The VA interval stabilized significantly earlier in AVRTs (median 1.5 [1 - 3] beats) than in aAVNRTs (5 [4 - 7] beats; p < 0.001). A ∆VA < 10 ms accurately differentiated AVRT from aAVNRT with 100% of sensitivity, specificity, and positive and negative predictive values. The stabilization of the VA interval at < 3 beats of the tachycardia onset identified AVRT with sensitivity, specificity, and positive and negative predictive values of 64.1%, 94.6%, 95.3%, and 60.3%, respectively. A ∆VA < 20 ms yielded good diagnostic accuracy for DAPT. CONCLUSIONS A ∆VA < 10 ms is a simple and useful criterion that accurately distinguished AVRT from atypical AVNRT. Central panel: Scatter plot showing individual values of ∆VA in atypical AVNRT and AVRT. Left panel: induction of atypical AVNRT. The VA interval stabilizes at the 5th beat and the ∆VA is 62 ms (maximum VA interval: 172 ms - minimum VA interval: 110 ms). Right panel: induction of AVRT. The tachycardia has a fixed VA interval from the first beat. ∆VA is 0 ms.
Collapse
Affiliation(s)
- Claudio Hadid
- Hospital General de Agudos Dr. Cosme Argerich, Pi y Margall 750, 1155, Ciudad Autónoma de Buenos Aires, Argentina. .,Hospital Universitario CEMIC, Ciudad Autónoma de Buenos Aires, Argentina. .,Sanatorio Garat, Concordia, Entre Ríos, Argentina. .,Cardiovascular Chivilcoy, Chivilcoy, Buenos Aires, Argentina.
| | - Leonardo Celano
- Hospital General de Agudos Dr. Cosme Argerich, Pi y Margall 750, 1155, Ciudad Autónoma de Buenos Aires, Argentina.,Hospital Universitario CEMIC, Ciudad Autónoma de Buenos Aires, Argentina
| | - Darío Di Toro
- Hospital General de Agudos Dr. Cosme Argerich, Pi y Margall 750, 1155, Ciudad Autónoma de Buenos Aires, Argentina.,Hospital Universitario CEMIC, Ciudad Autónoma de Buenos Aires, Argentina
| | - Edgar Antezana-Chavez
- Hospital General de Agudos Dr. Cosme Argerich, Pi y Margall 750, 1155, Ciudad Autónoma de Buenos Aires, Argentina
| | | | - Gustavo Iralde
- Cardiovascular Chivilcoy, Chivilcoy, Buenos Aires, Argentina
| | - David Calvo
- Arrhythmia Unit, Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria de Asturias, Oviedo, Spain
| | - Pablo Ávila
- Cardiology Department, Hospital General Universitario Gregorio Marañon, Instituto de Investigación Sanitaria Gregorio Marañon, Madrid, Spain.,Centre for Biomedical Research in Cardiovascular Disease Network (CIBERCV), Madrid, Spain
| | | | | | | | - Carlos Labadet
- Hospital General de Agudos Dr. Cosme Argerich, Pi y Margall 750, 1155, Ciudad Autónoma de Buenos Aires, Argentina.,Hospital Universitario CEMIC, Ciudad Autónoma de Buenos Aires, Argentina
| |
Collapse
|
6
|
Hollanda L, Sobral R, Luize C, Dietrich C, Cirenza C, de Paola A. Atrioventricular nodal reentrant tachycardia and the dilemma of reentry circuit components: A proof of concept. HeartRhythm Case Rep 2021; 7:439-441. [PMID: 34307024 PMCID: PMC8283425 DOI: 10.1016/j.hrcr.2021.03.022] [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: 11/21/2022] Open
Affiliation(s)
- Lucas Hollanda
- Hospital São Rafael, Salvador, Brazil.,Federal University of São Paulo, São Paulo, Brazil
| | | | | | - Cristiano Dietrich
- Federal University of São Paulo, São Paulo, Brazil.,Hospital Moriah, São Paulo, Brazil
| | | | | |
Collapse
|
7
|
Higuchi S, Im SI, Gerstenfeld EP, Scheinman MM. Two P waves followed by 1 QRS complex: What is the mechanism? Heart Rhythm 2021; 18:1243-1244. [PMID: 33957318 DOI: 10.1016/j.hrthm.2021.04.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 04/28/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Satoshi Higuchi
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California, San Francisco, California
| | - Sung Il Im
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California, San Francisco, California
| | - Edward P Gerstenfeld
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California, San Francisco, California
| | - Melvin M Scheinman
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California, San Francisco, California.
| |
Collapse
|
8
|
Tobiume T, Kato R, Matsuura T, Matsumoto K, Hara M, Takamori N, Taketani Y, Okawa K, Ise T, Kusunose K, Yamaguchi K, Yagi S, Fukuda D, Yamada H, Wakatsuki T, Soeki T, Sata M, Matsumoto K. Antegrade slow pathway mapping of typical atrioventricular nodal reentrant tachycardia based on direct slow pathway capture. J Arrhythm 2021; 37:128-139. [PMID: 33664895 PMCID: PMC7896471 DOI: 10.1002/joa3.12484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 11/14/2020] [Accepted: 11/30/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Radiofrequency (RF) ablation of typical atrioventricular nodal reentrant tachycardia (tAVNRT) is performed without revealing out the location of antegrade slow pathway (ASp). In this study, we studied a new electrophysiological method of identifying the site of ASp. METHODS This study included 19 patients. Repeated series of very high-output single extrastimulations (VhoSESts) were delivered at the anatomical slow pathway region during tAVNRT. Tachycardia cycle length (TCL), coupling interval (CI), and return cycle (RC) were measured and the prematurity of VhoSESts [ΔPM (= TCL - CI)] and the prolongation of RCs [ΔPL (= RC - TCL)] were calculated. Pacing sites were classified into two categories: (i) ASp capture sites [DSPC(+) sites], where two different RCs were shown, and ASp non-capture sites [DSPC(-) sites], where only one RC was shown. RF ablation was performed at DSPC(+) sites and/or sites with catheter-induced mechanical trauma (CIMT) to ASp. RESULTS DSPC(+) sites were shown in 13 patients (68%). RF ablation was successful in all patients without any degree of atrioventricular block nor recurrence. Total number of RF applications was 1.8 ± 1.1. Minimal distance between successful ablation sites and DSPC(+)/CIMT sites and His bundle (HB) electrogram recording sites was 1.9 ± 0.8 mm and 19.8 ± 6.1 mm, respectively. ΔPL of more than 92.5 ms, ΔPL/TCL of more than 0.286, and ΔPL/ΔPM of more than 1.565 could identify ASp with sensitivity of 100%, 91.1%, and 88.9% and specificity of 92.9%, 97.0%, and 97.6%, respectively. CONCLUSIONS Sites with ASp capture and CIMT were close to successful ablation sites and could be useful indicators of tAVNRT ablation.
Collapse
Affiliation(s)
- Takeshi Tobiume
- Department of CardiologyTokushima University HospitalTokushimaJapan
- Department of CardiologySaitama Medical University International Medical CenterHidakaJapan
- Department of CardiologyKawashima HospitalTokushimaJapan
- Department of CardiologyShikoku Medical Center for Children and AdultsZentsujiJapan
| | - Ritsushi Kato
- Department of CardiologySaitama Medical University International Medical CenterHidakaJapan
| | - Tomomi Matsuura
- Department of CardiologyTokushima University HospitalTokushimaJapan
| | | | - Motoki Hara
- Hara Clinic Higashi‐HiroshimaHigashi‐HiroshimaJapan
| | | | - Yoshio Taketani
- Department of CardiologyShikoku Medical Center for Children and AdultsZentsujiJapan
| | - Keisuke Okawa
- Department of CardiologyKagawa Prefectural Central HospitalTakamatsuJapan
| | - Takayuki Ise
- Department of CardiologyTokushima University HospitalTokushimaJapan
| | - Kenya Kusunose
- Department of CardiologyTokushima University HospitalTokushimaJapan
| | - Koji Yamaguchi
- Department of CardiologyTokushima University HospitalTokushimaJapan
| | - Shusuke Yagi
- Department of CardiologyTokushima University HospitalTokushimaJapan
| | - Daijyu Fukuda
- Department of CardiologyTokushima University HospitalTokushimaJapan
| | - Hirotsugu Yamada
- Department of CardiologyTokushima University HospitalTokushimaJapan
| | | | - Takeshi Soeki
- Department of CardiologyTokushima University HospitalTokushimaJapan
| | - Masataka Sata
- Department of CardiologyTokushima University HospitalTokushimaJapan
| | - Kazuo Matsumoto
- Department of CardiologySaitama Medical University International Medical CenterHidakaJapan
- Department of Internal MedicineHigashi‐Matsuyama Medical Association HospitalHigashimatsuyamaJapan
| |
Collapse
|
9
|
Munawar DA, Arstall M, Lypourlis D. The existence of upper common pathway: Evidence from concomitant atrioventricular nodal reentrant tachycardia and atrial fibrillation. HeartRhythm Case Rep 2021; 7:21-25. [PMID: 33505849 PMCID: PMC7813793 DOI: 10.1016/j.hrcr.2020.10.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Affiliation(s)
| | | | - Dimitrios Lypourlis
- Address reprint requests and correspondence: Dr Dimitrios Lypourlis, Department of Cardiology, Lyell McEwin Hospital, Haydown Road, Elizabeth Vale, Adelaide, South Australia, 5112, Australia.
| |
Collapse
|
10
|
Nagashima K, Kaneko Y, Maruyama M, Nogami A, Kowase S, Mori H, Sumitomo N, Fukamizu S, Hojo R, Kitamura T, Soejima K, Ueda A, Otsuka T, Takami M, Tanimoto K, Asakawa T, Kumagai K, Tamura S, Hasegawa H, Ogura K, Kawamura M, Munetsugu Y, Shoda M, Higuchi S, Kanazawa H, Kusa S, Mizukami A, Miyazaki S, Wakamatsu Y, Okumura Y. Novel Diagnostic Observations of Nodoventricular/Nodofascicular Pathway-Related Orthodromic Reciprocating Tachycardia Differentiating From Atrioventricular Nodal Re-Entrant Tachycardia. JACC Clin Electrophysiol 2020; 6:1797-1807. [PMID: 33357576 DOI: 10.1016/j.jacep.2020.07.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 06/29/2020] [Accepted: 07/06/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVES This study sought to assess the performance of current diagnostic criteria and identify additional electrophysiological features differentiating orthodromic reciprocating tachycardia (ORT) with a concealed nodoventricular/nodofascicular (NV/NF) pathway from atrioventricular nodal re-entrant tachycardia (AVNRT). BACKGROUND Diagnosing sustained supraventricular tachycardia (SVT) despite the occurrence of ventriculoatrial block (VAB) is challenging. METHODS We analyzed electrograms of 25 sustained SVTs (9 NV/NF-ORTs [n = 7/2] and 16 AVNRTs) with VAB and 91 AVNRTs without VAB (for reference). RESULTS More than 1 SVT, each with a different ventriculoatrial interval, was commonly induced in AVNRT cases (75%) but not in NV/NF-ORT cases (0%; p = 0.0005). Wenckebach VAB was common in NV/NF-ORTs (78%), but VAB patterns varied in AVNRTs. The His-His interval transiently prolonged in the following beat after the VAB in most AVNRTs but rarely did in NV/NF-ORTs (79% vs. 22%; p = 0.01). NV/NF-ORT was diagnosed by His-refractory premature ventricular contractions (n = 5) and the findings during right ventricular overdrive pacing showing an uncorrected/corrected post-pacing interval (PPI)-tachycardia cycle length (TCL) ≤115/110 ms (n = 5/5), orthodromic His capture (n = 6), and V-V-A (ventricle-ventricle-atrial response) response (n = 3). A single form of induced SVT (positive predictive value [PPV]: 69%; negative predictive value [NPV]: 100%), Wenckebach VAB (PPV: 70%; NPV: 87%), stable His-His interval despite VAB (PPV: 70%; NPV: 85%), orthodromic His capture (PPV: 100%; NPV: 97%), and V-V-A response (PPV: 100%; NPV: 95%) characterized NV/NF-ORT, and a PPI-TCL of ≤125 ms (PPV: 100%; NPV: 100%) characterized NV-ORT. CONCLUSIONS Induction of a single SVT form, Wenckebach VAB, stable His-His interval despite VAB, orthodromic His capture, and V-V-A response appeared to discriminate NV/NF-ORT from AVNRT, with a PPI-TCL of ≤125 ms discriminating NV-ORT from NF-ORT and AVNRT.
Collapse
Affiliation(s)
- Koichi Nagashima
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Ibaraki, Tokyo, Japan.
| | - Yoshiaki Kaneko
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Mitsunori Maruyama
- Department of Cardiovascular Medicine, Nippon Medical School Musashikosugi Hospital, Tokyo, Japan
| | - Akihiko Nogami
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan; Department of Heart Rhythm Management, Yokohama Rosai Hospital, Yokohama, Kanagawa, Japan
| | - Shinya Kowase
- Department of Heart Rhythm Management, Yokohama Rosai Hospital, Yokohama, Kanagawa, Japan
| | - Hitoshi Mori
- Department of Pediatric Cardiology, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Naokata Sumitomo
- Department of Pediatric Cardiology, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Seiji Fukamizu
- Department of Cardiology, Tokyo Metropolitan Hiroo Hospital, Shibuya, Tokyo, Japan
| | - Rintaro Hojo
- Department of Cardiology, Tokyo Metropolitan Hiroo Hospital, Shibuya, Tokyo, Japan
| | - Takeshi Kitamura
- Department of Cardiology, Tokyo Metropolitan Hiroo Hospital, Shibuya, Tokyo, Japan
| | - Kyoko Soejima
- Department of Cardiovascular Medicine, Kyorin University Hospital, Mitaka, Tokyo, Japan
| | - Akiko Ueda
- Division of Advance Arrhythmia Management, Kyorin University Hospital, Mitaka, Tokyo, Japan
| | - Takayuki Otsuka
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Kobe, Japan
| | - Mitsuru Takami
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kojiro Tanimoto
- Department of Cardiology, Tokyo Medical Center, Tokyo, Japan
| | - Tetsuya Asakawa
- Department of Cardiology, Yamanashi Kosei Hospital, Yamanashi, Japan
| | - Kenta Kumagai
- Department of Cardiology, Odawara Cardiovascular Hospital, Odawara, 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
| | - Kazuyoshi Ogura
- Division of Cardiovascular Medicine, Endocrinology and Metabolism, Department of Molecular Medicine and Therapeutics, Faculty of Medicine, Tottori University, Tottori, Japan
| | - Mitsuharu Kawamura
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Yumi Munetsugu
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Morio Shoda
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Satoshi Higuchi
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Hisanori Kanazawa
- Department of Cardiac Arrhythmias, Kumamoto University Hospital, Kumamoto, Japan
| | - Shigeki Kusa
- Division of Cardiology, Tsuchiura Kyodo Hospital, Tsuchiura, Japan
| | - Akira Mizukami
- Department of Cardiology, Kameda Medical Center, Kamagawa, Japan
| | - Shinsuke Miyazaki
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Yuji Wakamatsu
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Ibaraki, Tokyo, Japan
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Ibaraki, Tokyo, Japan
| |
Collapse
|
11
|
Pavri BB, Nicholas Ruggiero. Dual atrioventricular nodal pathways physiology and high-grade heart block. J Electrocardiol 2020; 62:138-141. [PMID: 32866914 DOI: 10.1016/j.jelectrocard.2020.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 06/11/2020] [Accepted: 07/29/2020] [Indexed: 10/23/2022]
Abstract
We report of case of an 87 year old lady with preexisting RBBB who developed LBBB after transcatheter aortic valve replacement (TAVR) for the treatment of severe aortic stenosis. She underwent pacemaker implantation, and subsequently developed high-grade atrioventricular (AV) block. Dual chamber pacing in the setting of complete heart block with a long programmed AV delay showed retrograde P waves. Ventricular pacing showed intact retrograde conduction. Shortening the programmed AV delay resulted in loss of retrograde P waves during dual chamber pacing. These findings are discussed.
Collapse
Affiliation(s)
- Behzad B Pavri
- Thomas Jefferson University Hospital, 111 So 11(th) Street, Philadelphia, PA 19107, United States of America.
| | - Nicholas Ruggiero
- Thomas Jefferson University Hospital, 111 So 11(th) Street, Philadelphia, PA 19107, United States of America
| |
Collapse
|
12
|
Anderson RH, Sanchez-Quintana D, Mori S, Cabrera JA, Back Sternick E. Re-evaluation of the structure of the atrioventricular node and its connections with the atrium. Europace 2020; 22:821-830. [DOI: 10.1093/europace/euaa031] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Accepted: 01/24/2020] [Indexed: 11/14/2022] Open
Abstract
Abstract
Aims
The anatomic substrates for atrioventricular nodal re-entry remain enigmatic, but require knowledge of the normal arrangement of the inputs and exist from the atrioventricular node. This knowledge is crucial to understand the phenomenon of atrioventricular nodal re-entry.
Methods and results
We studied 20 human hearts with serial sections covering the entirety of the triangle of Koch and the cavotricuspid isthmus. We determined the location of the atrioventricular conduction axis and the connections between the specialized cardiomyocytes of the conduction axis and the adjacent working atrial myocardium. The atrioventricular node was found at the apex of the triangle of Koch, with entry of the conduction axis to the central fibrous body providing the criterion for distinction of the bundle of His. We found marked variation in the inferior extensions of the node, the shape of the node, the presence or absence of a connecting bridge within the myocardium of the cavotricuspid isthmus, the connections between the compact node and the myocardium of the atrial septum, the presence of transitional cardiomyocytes, and the ‘last’ connection between the working atrial myocardium and the conduction axis before it became the bundle of His.
Conclusion
The observed variations of the inferior extensions, combined with the arrangement of the ‘last’ connections between the atrial myocardium and the conduction axis prior to its insulation as the bundle of His, provide compelling evidence to support the concept for atrioventricular nodal re-entry as advanced by Katritsis and Becker.
Collapse
Affiliation(s)
- Robert H Anderson
- Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK
| | | | - Shumpei Mori
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Jose Angel Cabrera
- Departamento de Cardiología, Unidad de Arritmias, Hospital Universitario Quirón-Salud, Madrid and Complejo Hospitalario Ruber Juan Bravo, Universidad Europea de Madrid, Madrid, Spain
| | | |
Collapse
|
13
|
Okishige K, Shigeta T, Nakamura RA, Hirao T, Yoshida H, Yamauchi Y. Lower common pathway location detected by cryoablation of atrioventricular nodal reentrant tachycardia of the common variety. Clin Case Rep 2019; 7:2202-2206. [PMID: 31788279 PMCID: PMC6878096 DOI: 10.1002/ccr3.2392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 07/15/2019] [Accepted: 08/06/2019] [Indexed: 11/07/2022] Open
Abstract
As different from radiofrequency current energy, cryofreezing energy is able to provide reversible effects on cardiac tissue, called "cryomapping," which enables us to predict the effects of a subsequent application of ablative energy. Cryomapping is able to delineate the anatomical location of the lower common pathway of atrioventricular nodal reentrant tachycardia.
Collapse
Affiliation(s)
- Kaoru Okishige
- Heart CenterJapan Red Cross Yokohama City Bay HospitalYokohamaJapan
| | | | - Rena A. Nakamura
- Heart CenterJapan Red Cross Yokohama City Bay HospitalYokohamaJapan
| | - Tatsuhiko Hirao
- Heart CenterJapan Red Cross Yokohama City Bay HospitalYokohamaJapan
| | - Hiroshi Yoshida
- Heart CenterJapan Red Cross Yokohama City Bay HospitalYokohamaJapan
| | | |
Collapse
|
14
|
Ozeke O, Cay S, Ozcan F, Topaloglu S, Aras D. Electrophysiological maneuvers for concealed nodofascicular or upper common pathways: Positive findings always work, but negative findings does not. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2019; 42:392-393. [PMID: 30653677 DOI: 10.1111/pace.13604] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Accepted: 01/06/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Ozcan Ozeke
- Department of Cardiology, Turkiye Yuksek Ihtisas Training and Research Hospital, Health Sciences University, Ankara, Turkey
| | - Serkan Cay
- Department of Cardiology, Turkiye Yuksek Ihtisas Training and Research Hospital, Health Sciences University, Ankara, Turkey
| | - Firat Ozcan
- Department of Cardiology, Turkiye Yuksek Ihtisas Training and Research Hospital, Health Sciences University, Ankara, Turkey
| | - Serkan Topaloglu
- Department of Cardiology, Turkiye Yuksek Ihtisas Training and Research Hospital, Health Sciences University, Ankara, Turkey
| | - Dursun Aras
- Department of Cardiology, Turkiye Yuksek Ihtisas Training and Research Hospital, Health Sciences University, Ankara, Turkey
| |
Collapse
|
15
|
Ho RT. The ongoing mystery of the atrioventricular node. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2019; 42:753. [DOI: 10.1111/pace.13594] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 12/26/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Reginald T. Ho
- Division of CardiologyDepartment of MedicineThomas Jefferson University Hospital Philadelphia PA USA
| |
Collapse
|
16
|
Watanabe T, Hachiya H, Kusa S, Kajiyama T, Yamao K, Miyazaki S, Igarashi M, Nakamura H, Imai Y, Kario K, Iesaka Y. Utility of low-dose adenosine triphosphate sensitivity in slow-fast atrioventricular nodal reentrant tachycardia. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2019; 42:267-274. [PMID: 30569491 DOI: 10.1111/pace.13590] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 12/04/2018] [Accepted: 12/09/2018] [Indexed: 11/26/2022]
Abstract
PURPOSE Low-dose adenosine triphosphate (LD-ATP) is useful for diagnosing ATP-sensitive atrial tachycardia. However, the clinical implications of the sensitivity of LD-ATP in atrioventricular nodal reentrant tachycardia (AVNRT) still remain unknown. This study aimed to evaluate the mechanism of LD-ATP sensitivity in slow-fast AVNRT. METHODS We estimated the sensitivity of LD-ATP in slow-fast AVNRT by a 2-4-mg ATP intravenous injection during the tachycardia. We evaluated the atrial-His (A-H) interval, tachycardia termination mode, prevalence of a lower common pathway (LCP), and successful ablation site in slow-fast AVNRT with LD-ATP sensitivity. LCPs were defined as His-atrial interval differences of at least 5 ms between that during ventricular pacing at the tachycardia cycle length and that during the tachycardia. RESULTS Twenty-eight patients (mean age = 58 ± 11 years old, 18 females) with slow-fast AVNRT, who underwent catheter ablation of the antegrade slow pathway, were enrolled. Seventeen of 28 (61%) patients had LD-ATP sensitivity defined as termination of the tachycardia and/or a prolongation of the A-H interval of over 30 ms after an LD-ATP injection. The patients with LD-ATP sensitivity had a significantly higher prevalence of an LCP than those without (15/17 vs0/11, P < 0.0001). The successful ablation site in the LD-ATP sensitive group was significantly closer to the His bundle area than that in the LD-ATP nonsensitive group (13.3 ± 3.8 vs 20.5 ± 5.4 mm; distance to His bundle area in the left anterior oblique fluoroscopic view, P < 0.0001). CONCLUSIONS LD-ATP sensitivity in slow-fast AVNRT may suggest the existence of an LCP. The successful ablation site in patients with LD-ATP sensitivity could be closer to the His bundle region.
Collapse
Affiliation(s)
- Tomonori Watanabe
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Ibaraki, Japan.,Division of Cardiovascular Medicine, Department of Internal Medicine, Jichi Medical University, Tochigi, Japan
| | - Hitoshi Hachiya
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Ibaraki, Japan
| | - Shigeki Kusa
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Ibaraki, Japan
| | | | - Kazuya Yamao
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Ibaraki, Japan
| | | | - Miyako Igarashi
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Ibaraki, Japan
| | | | - Yasushi Imai
- Division of Cardiovascular Medicine, Department of Internal Medicine, Jichi Medical University, Tochigi, Japan
| | - Kazuomi Kario
- Division of Cardiovascular Medicine, Department of Internal Medicine, Jichi Medical University, Tochigi, Japan
| | - Yoshito Iesaka
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Ibaraki, Japan
| |
Collapse
|
17
|
Iqbal M, Munawar M, Pramudya A, Karwiky G, Achmad C. Persistent VA dissociation during atrioventricular nodal reentry tachycardia: The existence of upper common pathway. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2019; 42:749-752. [PMID: 30609078 PMCID: PMC6850433 DOI: 10.1111/pace.13595] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 12/05/2018] [Accepted: 12/13/2018] [Indexed: 11/29/2022]
Abstract
The existence of the upper common pathways is not well-established yet. This case describes atrioventricular nodal reentry tachycardia with persistent ventriculoatrial dissociation that proof of upper common pathway existence.
Collapse
Affiliation(s)
- Mohammad Iqbal
- Department of Cardiology and Vascular Medicine, Universitas Padjadjaran, Bandung, Indonesia.,Binawaluya Cardiac Center, Jakarta, Indonesia
| | - Muhammad Munawar
- Department of Cardiology and Vascular Medicine, Universitas Padjadjaran, Bandung, Indonesia.,Binawaluya Cardiac Center, Jakarta, Indonesia
| | - Arsha Pramudya
- Department of Cardiology and Vascular Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Giky Karwiky
- Department of Cardiology and Vascular Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Chaerul Achmad
- Department of Cardiology and Vascular Medicine, Universitas Padjadjaran, Bandung, Indonesia
| |
Collapse
|
18
|
Hadid C, Gonzalez S, Almendral J. Atrioventricular nodal reentrant tachycardia: Evidence of an upper common pathway in some patients. HeartRhythm Case Rep 2018; 4:227-231. [PMID: 29922580 PMCID: PMC6006418 DOI: 10.1016/j.hrcr.2018.02.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Affiliation(s)
- Claudio Hadid
- Hospital General de Agudos Cosme Argerich, Buenos Aires, Argentina
| | | | - Jesús Almendral
- Grupo HM Hospitales, University CEU-San Pablo, Madrid, Spain
| |
Collapse
|
19
|
Miller JM. Mark E Josephson: Clinical Investigator. Arrhythm Electrophysiol Rev 2017; 6:9-12. [PMID: 28507738 DOI: 10.15420/aer.2017.6.1:ed3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Mark E Josephson entered the world of clinical cardiac electrophysiology (EP) almost at its inception (1972); with so much to learn and so many directions one could take, he dived into the field with unbridled enthusiasm and an uncommon - perhaps almost unique - aptitude for asking questions and finding ways to answer them. Few aspects of EP escaped his indelible influence. In this short paper, I will attempt to touch on some of the high points of his astounding career as a clinical investigator.
Collapse
Affiliation(s)
- John M Miller
- Indiana University School of Medicine; Indiana University Health, Indianapolis, USA
| |
Collapse
|
20
|
Katritsis DG, Josephson ME. Classification, Electrophysiological Features and Therapy of Atrioventricular Nodal Reentrant Tachycardia. Arrhythm Electrophysiol Rev 2016; 5:130-5. [PMID: 27617092 DOI: 10.15420/aer.2016.18.2] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Atrioventricular nodal reentrant tachycardia (AVNRT) should be classified as typical or atypical. The term 'fast-slow AVNRT' is rather misleading. Retrograde atrial activation during tachycardia should not be relied upon as a diagnostic criterion. Both typical and atypical atrioventricular nodal reentrant tachycardia are compatible with varying retrograde atrial activation patterns. Attempts at establishing the presence of a 'lower common pathway' are probably of no practical significance. When the diagnosis of AVNRT is established, ablation should be only directed towards the anatomic position of the slow pathway. If right septal attempts are unsuccessful, the left septal side should be tried. Ablation targeting earliest atrial activation sites during typical atrioventricular nodal reentrant tachycardia or the fast pathway in general for any kind of typical or atypical atrioventricular nodal reentrant tachycardia, are not justified. In this review we discuss current concepts about the tachycardia circuit, electrophysiologic diagnosis, and ablation of this arrhythmia.
Collapse
Affiliation(s)
| | - Mark E Josephson
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
21
|
Optimal slow pathway ablation site for slow-fast atrioventricular nodal reentrant tachycardia with 2:1 atrioventricular conduction. J Interv Card Electrophysiol 2016; 48:209-214. [DOI: 10.1007/s10840-016-0176-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 08/11/2016] [Indexed: 11/26/2022]
|
22
|
Katritsis DG, Josephson ME. Classification of electrophysiological types of atrioventricular nodal re-entrant tachycardia: a reappraisal. ACTA ACUST UNITED AC 2013; 15:1231-40. [DOI: 10.1093/europace/eut100] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
|
23
|
WOOD MARK, KISER ROBERT, ELLENBOGEN KENNETH. Atrioventricular Nodal Reentry with Retrograde Lower Common Pathway Block: A Case Report. J Cardiovasc Electrophysiol 2011; 22:934-7. [DOI: 10.1111/j.1540-8167.2010.01991.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
24
|
CANO OSCAR, OSCA JOAQUÍN, SANCHO-TELLO MARÍAJOSÉ, OLAGÜE JOSÉ. Grouped Beating during Narrow Complex Tachycardia: What Is the Mechanism? Pacing Clin Electrophysiol 2010; 33:1031-4. [DOI: 10.1111/j.1540-8159.2010.02744.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
25
|
ROSHAN JOHN, LOKHANDWALA YASH. The Road Not Taken. Pacing Clin Electrophysiol 2009; 32:788-90. [DOI: 10.1111/j.1540-8159.2009.02367.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
26
|
Mahajan T, Berul CI, Cecchin F, Triedman JK, Alexander ME, Walsh EP. Atrioventricular nodal reentrant tachycardia with 2:1 block in pediatric patients. Heart Rhythm 2008; 5:1391-5. [PMID: 18929325 DOI: 10.1016/j.hrthm.2008.06.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2008] [Accepted: 06/21/2008] [Indexed: 11/17/2022]
Abstract
BACKGROUND Episodic 2:1 block occurs in 9% of adults with atrioventricular nodal reentry tachycardia (AVNRT), but developmental differences in conduction physiology among children could influence this phenomenon. OBJECTIVE This study sought to characterize the frequency and mechanism of 2:1 block during AVNRT in the pediatric population. METHODS Records of 179 patients (mean age 13.5 +/- 3.4 years) undergoing ablation for AVNRT were reviewed. RESULTS Periods of 2:1 AVNRT were observed in 31 cases (17%). A His potential was visible on the blocked beats of 13, absent in 17, and undetermined in 1. Compared with 148 patients with exclusive 1:1 conduction, those with 2:1 AVNRT had: (1) longer baseline slow pathway refractory period (351 +/- 71 msec vs. 278 +/- 65 msec, P =.04), (2) shorter atrial cycle length during AVNRT (303 +/- 54 msec vs. 333 +/- 62 msec, P =.01), and (3) a higher incidence of bundle-branch aberration (35% vs. 18%, P =.03). Long-short oscillations in atrial cycle length were observed in 55% of patients during 2:1 AVNRT, but not during 1:1 AVNRT. CONCLUSION A pattern of 2:1 block occurs in 17% of pediatric patients with AVNRT undergoing ablation. Although this incidence is higher than in older patients, the mechanism appears identical. These data provide further evidence that functional block within or below the His bundle is the mechanism of 2:1 AVNRT, regardless of the presence of a His potential. Oscillations in atrial cycle length are common during 2:1 AVNRT in children and may contribute to the block pattern, but are not a requisite.
Collapse
Affiliation(s)
- Tarun Mahajan
- Department of Cardiology, Children's Hospital Boston, Harvard Medical School, Boston Massachusetts 02115, USA
| | | | | | | | | | | |
Collapse
|
27
|
|
28
|
Irregular atypical atrioventricular nodal reentrant tachycardia: Incidence, electrophysiological characteristics, and effects of slow pathway ablation. Heart Rhythm 2007; 4:1507-22. [DOI: 10.1016/j.hrthm.2007.08.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2007] [Accepted: 08/10/2007] [Indexed: 11/18/2022]
|
29
|
KATRITSIS DEMOSTHENESG. Upper and Lower Common Pathways in Atrioventricular Nodal Reentrant Tachycardia:. Refutation of a Legend? PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2007; 30:1305-8. [DOI: 10.1111/j.1540-8159.2007.00861.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
30
|
SRIVATHSAN KOMANDOOR, GAMI APOORS, BARRETT RENEE, MONAHAN KRISTI, PACKER DOUGLASL, ASIRVATHAM SAMUELJ. Differentiating Atrioventricular Nodal Reentrant Tachycardia from Junctional Tachycardia: Novel Application of the Delta H-A Interval. J Cardiovasc Electrophysiol 2007; 19:1-6. [DOI: 10.1111/j.1540-8167.2007.00961.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
|
31
|
Katritsis DG, Becker A. The atrioventricular nodal reentrant tachycardia circuit: A proposal. Heart Rhythm 2007; 4:1354-60. [PMID: 17905343 DOI: 10.1016/j.hrthm.2007.05.026] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2007] [Accepted: 05/24/2007] [Indexed: 11/17/2022]
Abstract
Several models of the atrioventricular nodal reentrant tachycardia circuit have been proposed. Recently, there has been experimental and clinical electrophysiology evidence that the right and left inferior extensions of the human atriventricular node and the atrionodal inputs they facilitate may provide the anatomic substrate of the slow pathway. Inferior nodal extensions appear to constitute a necessary limb of the tachycardia circuit in all forms of atrioventricular nodal reentrant tachycardia and represent the ablation target for all forms of this arrhythmia. Anatomic variations of multiple atrionodal inputs via atrial transitional cells may create the conditions for tachycardia inducibility and differing patterns of retrograde atrial activation. In the present article, we summarize the available evidence and propose a comprehensive model of the tachycardia circuit for all forms of atrioventricular nodal reentrant tachycardia based on the concept of atrionodal inputs.
Collapse
|
32
|
Otomo K, Suyama K, Okamura H, Noda T, Satomi K, Shimizu W, Kurita T, Aihara N, Kamakura S. Implications of 2:1 atrioventricular block during typical atrioventricular nodal reentrant tachycardia. J Interv Card Electrophysiol 2007; 19:109-19. [PMID: 17668303 DOI: 10.1007/s10840-007-9147-4] [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] [Received: 04/11/2007] [Accepted: 06/26/2007] [Indexed: 12/01/2022]
Abstract
OBJECTIVE The effects of 2:1 AV block (AVB) on AV nodal reentrant tachycardia (AVNRT) remain to be elucidated. This study was performed to localize the site of 2:1 AVB and elucidate the effects of 2:1 AVB on typical AVNRT. METHODS The His bundle (HB) electrograms during typical AVNRT with 2:1 AV block were reviewed in 24 patients. It was hypothesized that if 2:1 AVB at the HB or below changed tachycardia cycle length (TCL), the lower turnaround point of the reentrant circuit (RC) might be located within the HB and parts of the HB might be involved in the RC. RESULTS A HB potential was absent in blocked beats during 2:1 AVB in four patients (supra-Hisian block), and the maximal amplitude of the HB potential in blocked beats was the same as that in conducted beats in four patients (infra-Hisian block), and was significantly smaller than that in conducted beats (0.1 +/- 0.1 versus 0.5 +/- 0.2 mV, P < 0.05) in 16 patients (intra-Hisian block). Eight patients (33%) with intra-Hisian block had a nearly identical prolongation of the H-A and A-A intervals in blocked beats (12 +/- 3 and 13 +/- 2 ms, respectively) with unchanged A-H intervals, while the remaining 16 patients (67%) exhibited invariable A-A and/or H-A intervals. CONCLUSION The site of 2:1 AVB during typical AVNRT was estimated to be at the HB or below in 83% of the cases. Two-to-one intra-Hisian block transiently prolonged TCL, possibly indicating involvement of the proximal HB in the RC in one-third of typical the AVNRT cases with 2:1 AVB.
Collapse
Affiliation(s)
- Kiyoshi Otomo
- Division of Cardiology, National Cardiovascular Center, Suita, Japan.
| | | | | | | | | | | | | | | | | |
Collapse
|
33
|
Katritsis DG. Is there an upper common pathway in AVNRT? Heart Rhythm 2007; 4:1119; author reply 1119-20. [PMID: 17675097 DOI: 10.1016/j.hrthm.2007.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2007] [Indexed: 11/23/2022]
|
34
|
Palanca V, Quesada A, Jimenez J, Jacas V. Wide QRS tachycardia with ventriculoatrial dissociation in early postoperative aortic valve replacement period: an atypical nodal reentry presentation. Cardiology 2007; 109:68-72. [PMID: 17627112 DOI: 10.1159/000105329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2006] [Accepted: 10/27/2006] [Indexed: 11/19/2022]
Abstract
We report an atypical presentation of atrioventricular (AV) nodal reentry tachycardia with periods of ventriculoatrial Wenckebach and complete ventriculoatrial dissociation which appeared in a male patient in the postoperative period following aortic valve replacement and plication of Valsalva's posterior sinus. The context for the onset of this AV nodal reentry tachycardia and the concurrent electrophysiological findings support the hypothesis of a strictly nodal location of the circuit and suggest that the electrical modifications sustained by the perinodal region are the triggering agent for the reentry mechanism. Therefore, the AV nodal reentry is a mechanism that must be considered when tachycardia appears in the early postoperative period following aortic valve replacement.
Collapse
Affiliation(s)
- Victor Palanca
- Arrhythmia and Cardiac Pacing Unit, Cardiology Service, Consorcio Hospital General Universitario, Valencia, Spain.
| | | | | | | |
Collapse
|
35
|
Otomo K, Suyama K, Okamura H, Noda T, Satomi K, Shimizu W, Kurita T, Aihara N, Kamakura S. Participation of a concealed atriohisian tract in the reentrant circuit of the slow–fast type of atrioventricular nodal reentrant tachycardia. Heart Rhythm 2007; 4:703-10. [PMID: 17556188 DOI: 10.1016/j.hrthm.2007.02.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2007] [Accepted: 02/12/2007] [Indexed: 11/20/2022]
Abstract
BACKGROUND The retrograde fast pathway in typical atrioventricular nodal reentrant tachycardia (AVNRT) exhibits marked variation in its electrophysiologic properties. OBJECTIVE The purpose of this study was to characterize the retrograde fast pathway and localize the lower turnaround site of the reentrant circuit in typical AVNRT. METHODS Seventy-four patients with typical AVNRT were divided into two groups according to the response of the retrograde fast pathway to intravenous administration of adenosine triphosphate (ATP) during ventricular pacing: ATP-S [n = 47 (63.5%)] with and ATP-R without [n = 27 (36.5%)] His-atrial (H-A) block. H-A intervals were measured from the most proximal His-bundle electrogram to the earliest atrial activation during the tachycardia (HAt) and entrainment pacing from the parahisian right ventricular region (HAe). It was postulated that the HAt was the difference in conduction time between the lower common pathway (x) and retrograde fast pathway (y) (HAt = y - x), whereas HAe was the sum of the two (HAe = y + x). Hence, x = (HAe-HAt)/2. x >0 suggested the presence of a lower common pathway, whereas x <0 suggested the absence of a lower common pathway and lower turnaround site within the His bundle. RESULTS x was significantly smaller in ATP-R than ATP-S (-6 +/- 5 vs 4 +/- 4 ms, P <.05) and was <0 in 23 (85%) of 27 ATP-R patients. The maximal increment in H-A interval during ventricular pacing was significantly longer in ATP-S than ATP-R (35 +/- 33 vs 2 +/- 2 ms, P <.05). CONCLUSION A concealed atriohisian tract totally bypassing the atrioventricular node constituted the retrograde fast pathway in one third of all typical AVNRT cases.
Collapse
Affiliation(s)
- Kiyoshi Otomo
- Division of Cardiology, National Cardiovascular Center, Suita, Japan.
| | | | | | | | | | | | | | | | | |
Collapse
|
36
|
Abstract
This article reviews progress in the understanding of AV junctional reentrant tachycardia and accessory pathway-mediated tachycardia in the twentieth century and in the early part of the twenty-first century. Emphasis is placed on the contributions of John Uther and the department he founded at Westmead Hospital.
Collapse
Affiliation(s)
- Mark A McGuire
- Department of Cardiology, Royal Prince Alfred Hospital, Camperdown NSW, Australia.
| |
Collapse
|
37
|
Atypical atrioventricular nodal reentrant tachycardia with eccentric coronary sinus activation: Electrophysiological characteristics and essential effects of left-sided ablation inside the coronary sinus. Heart Rhythm 2007; 4:421-32. [DOI: 10.1016/j.hrthm.2006.12.035] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2006] [Accepted: 12/15/2006] [Indexed: 11/20/2022]
|
38
|
Yamada T, Huizar JF, McElderry HT, Kay GN. Atrial tachycardia with slow pathway conduction mimicking typical atrioventricular nodal reentrant tachycardia. ACTA ACUST UNITED AC 2007; 9:299-301. [PMID: 17363425 DOI: 10.1093/europace/eum037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
A 68-year-old woman with palpitations underwent electrophysiologic testing. During burst atrial pacing the PR interval exceeded the RR interval and induced a supraventricular tachycardia consistent with a typical AV nodal reentrant tachycardia (AVNRT). Radiofrequency ablation of the slow pathway during the tachycardia immediately produced 2 : 1 AV conduction. After slow AV nodal pathway ablation an atrial tachycardia (AT) remained inducible with the earliest atrial activation around the HB region. Radiofrequency ablation at the site of earliest atrial activation interrupted the AT without AV block. AT originating from the HB region with slow pathway conduction may mimic typical AVNRT.
Collapse
Affiliation(s)
- Takumi Yamada
- Division of Cardiovascular Diseases, Cardiac Rhythm Management Laboratory, University of Alabama at Birmingham, VH B147, 1670 University Boulevard, 1530 3rd AVE S, Birmingham, AL 35294-0019, USA.
| | | | | | | |
Collapse
|
39
|
Luis Merino J. Ablación de la taquicardia intranodal: cuando la fisiología cuenta en la era de la anatomía. Rev Esp Cardiol (Engl Ed) 2007. [DOI: 10.1016/s0300-8932(07)74978-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
40
|
Otomo K, Okamura H, Noda T, Satomi K, Shimizu W, Suyama K, Kurita T, Aihara N, Kamakura S. Unique electrophysiologic characteristics of atrioventricular nodal reentrant tachycardia with different ventriculoatrial block patterns: effects of slow pathway ablation and insights into the location of the reentrant circuit. Heart Rhythm 2006; 3:544-54. [PMID: 16648059 DOI: 10.1016/j.hrthm.2006.01.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2005] [Accepted: 01/20/2006] [Indexed: 10/25/2022]
Abstract
BACKGROUND The electrophysiologic mechanisms of different ventriculoatrial (VA) block patterns during atrioventricular nodal reentrant tachycardia (AVNRT) are poorly understood. OBJECTIVES The purpose of this study was to characterize AVNRTs with different VA block patterns and to assess the effects of slow pathway ablation. METHODS Electrophysiologic data from six AVNRT patients with different VA block patterns were reviewed. RESULTS All AVNRTs were induced after a sudden AH "jump-up" with the earliest retrograde atrial activation at the right superoparaseptum. Different VA block patterns comprised Wenckebach His-atrial (HA) block (n = 4), 2:1 HA block (n = 1), and variable HA conduction times during fixed AVNRT cycle length (CL) (n = 1). Wenckebach HA block during AVNRT was preceded by gradual HA interval prolongation with fixed His-His (HH) interval and unchanged atrial activation sequence. AVNRT with 2:1 HA block was induced after slow pathway ablation for slow-slow AVNRT with 1:1 HA conduction, and earliest atrial activation shifted from right inferoparaseptum to superoparaseptum without change in AVNRT CL. The presence of a lower common pathway was suggested by a longer HA interval during ventricular pacing at AVNRT CL than during AVNRT (n = 5) or Wenckebach HA block during ventricular pacing at AVNRT CL (n = 1). In four patients, HA interval during ventricular pacing at AVNRT CL was unusually long (188 +/- 30 ms). Ablations at the right inferoparaseptum rendered AVNRT noninducible in 5 (83%) of 6 patients. CONCLUSION Most AVNRTs with different VA block patterns were amenable to classic slow pathway ablation. The reentrant circuit could be contained within a functionally protected region around the AV node and posterior nodal extensions, and different VA block patterns resulted from variable conduction at tissues extrinsic to the reentrant circuit.
Collapse
Affiliation(s)
- Kiyoshi Otomo
- Division of Cardiology, National Cardiovascular Center, Suita, Japan.
| | | | | | | | | | | | | | | | | |
Collapse
|
41
|
Abstract
Though patients with AV nodal reentry are now routinely cured by catheter ablation, the basic mechanism of this disorder is still under debate. The putative mechanism of AV node reentry was first discovered by the elegant work of Gordon Moe. He demonstrated the existence of dual pathways and echo beats in rabbits. Building on these seminal observations, the mechanism of AVNRT has burgeoned to include the possibility of left atrial input into the node. The first curative nonpharmacologic procedures involved surgical dissection around the AV node and the procedure was rapidly supplanted by catheter ablation procedures. The initial ablative procedure targeted the fast pathway, but later observations showed that ablation of the slow pathway was more effective and safer. Cure of AV nodal reentry which is the most common cause of paroxysmal supraventricular tachycardia became possible through the cooperative efforts of anatomists, physiologists, surgeons, and clinical electrophysiologists.
Collapse
|
42
|
Katritsis DG, Camm AJ. Classification and differential diagnosis of atrioventricular nodal re-entrant tachycardia. ACTA ACUST UNITED AC 2006; 8:29-36. [PMID: 16627405 DOI: 10.1093/europace/euj010] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Recent evidence on atrioventricular nodal re-entrant tachycardia has identified several types of this common arrhythmia, with potential therapeutic implications. This article reviews the relevant new information, discusses the differential diagnosis of atrioventricular nodal re-entrant tachycardia, and summarizes the electrophysiological criteria for classification of the various forms of the arrhythmia.
Collapse
|
43
|
Lau EW, Green MS, Gow R, Tang ASL. Paroxysmal supraventricular tachycardia with atrioventricular block: What is the mechanism? Heart Rhythm 2005; 2:207-9. [PMID: 15851300 DOI: 10.1016/j.hrthm.2004.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Ernest W Lau
- University of Ottawa Heart Institute, Ontario, Canada
| | | | | | | |
Collapse
|
44
|
Katsiyiannis WT, Chen J. Narrow QRS Complex Tachycardia:. What Is the Mechanism? Pacing Clin Electrophysiol 2004; 27:993-5. [PMID: 15271021 DOI: 10.1111/j.1540-8159.2004.00570.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- William T Katsiyiannis
- Cardiovascular Division, Washington University School of Medicine, St. Louis, Missouri, USA
| | | |
Collapse
|
45
|
Yagi T, Yang Y, Keung EC, Collins KK, Scheinman MM. Significance of bundle branch block during atrioventricular nodal reentrant tachycardia. Am J Cardiol 2003; 91:1184-9. [PMID: 12745100 DOI: 10.1016/s0002-9149(03)00264-9] [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: 11/20/2022]
Abstract
There are very limited data on the effects of bundle branch block (BBB) in patients with atrioventricular nodal reentrant tachycardia (AVNRT). Studies in a total of 155 patients with 162 episodes of AVNRT were retrospectively analyzed. A total of 38 patients (25%) developed spontaneous right BBB, whereas 5 (3%) developed left BBB during tachycardia. Five of the 38 (13%) with right BBB showed near identical prolongation of both the ventriculoatrial (VA) (15 +/- 5 ms; 10 to 23) and His to atrial intervals (HA) (14 +/- 4 ms; 10 to 20) with an identical atrial activation sequence for both right BBB or normal QRS tachycardia complexes. In contrast, all 5 patients with left BBB showed a decrease in the VA (-18 +/- 11 ms; 10 to 36) with unchanged HA comparing left BBB to normal QRS patterns during AVNRT. The magnitude of prolongation of the His to ventricular interval (HV) during left BBB (19 +/- 12 ms; 10 to 40) was nearly identical to the decrease in the VA. In conclusion, prolongation of VA and HA with unchanged HV in patients with AVNRT and right BBB suggests that right BBB is due to a block in the fibers in close proximity to the His recording site. The data suggest that fibers in the His bundle are predestined to activate the right bundle branch, and in AVNRT the lower turnaround point may be within the His bundle.
Collapse
Affiliation(s)
- Tetsuo Yagi
- Cardiac Electrophysiology, University of California San Francisco, 94143-1354, USA
| | | | | | | | | |
Collapse
|
46
|
Guo HM, Nerheim P, Olshansky B. Irregular atrial activation during atrioventricular nodal reentrant tachycardia: evidence of an upper common pathway. J Cardiovasc Electrophysiol 2003; 14:309-13. [PMID: 12716116 DOI: 10.1046/j.1540-8167.2003.02430.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Controversy continues regarding the precise nature of the reentrant circuit of AV nodal reentrant tachycardia, especially the existence of an upper common pathway. In this case report, we show that marked variation and irregularity in atrial activation (maximum AA interval variation of 80 msec) can exist with fixed and constant activation of the His bundle and ventricles during AV nodal reentrant tachycardia in a 45-year-old female patient. We propose that irregular atrial activation is due to variable and inconsistent conduction from the AV node to the atria through the perinodal transitional cell envelope extrinsic to the reentrant circuit. Our observations support the concept of an upper common pathway, at least in some patients with AV nodal reentrant tachycardia.
Collapse
Affiliation(s)
- Hongsheng M Guo
- University of Iowa Hospitals and Clinics, Iowa City, Iowa 52242, USA
| | | | | |
Collapse
|
47
|
Abstract
Atrioventricular node reentry tachycardia (AVNRT) is a significant cause of paroxysmal supraventricular tachycardia (SVT) in the pediatric population. Symptoms can include palpitations, chest pain, fatigue, light-headedness and syncope. AVNRT is a reentry tachycardia that is comprised of dual conduction pathways through the AV node. On electrocardiogram, AVNRT usually manifests as a regular tachycardia with a narrow QRS complex and P waves that are either absent or distort the terminal portion of the QRS complex. Electrophysiology study will reveal dual AV node pathways: a fast pathway with a short AH interval and a long effective refractory period (ERP); and a slow pathway with a longer AH interval and a shorter ERP. During tachycardia, electrophysiologic signals will reveal conduction up the midline. Introduction of premature ventricular contractions and measurement of the HA interval during SVT can help distinguish AVNRT from a SVT utilizing an accessory pathway. Radiofrequency catheter ablation (RFA) has been used increasingly in children as treatment for AVNRT. The initial approach to RFA of AVNRT was modification of AV fast pathway conduction by lesions placed near the anterosuperior aspect of the triangle of Koch, known as the anterior approach method. However, this technique was associated with a significant risk of complete AV block. Now, the posterior approach slow pathway modification is used more commonly, which positions the ablation catheter along the tricuspid annulus immediately anterior to the coronary sinus ostium. This has been associated with a lower risk of complete AV block. Using this technique, RFA should be considered the method of choice for curative therapy of AVNRT in pediatric patients.
Collapse
Affiliation(s)
- P S. Ro
- Department of Pediatrics, University of Pennsylvania School of Medicine and Division of Cardiology, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, 19104, Philadelphia, PA, USA
| | | |
Collapse
|
48
|
Kantharia BK, Mittleman RS. Case report: anterograde 2:1 and retrograde 3:2 Wenckebach block during atrioventricular nodal tachycardia: controversies of the upper and lower common pathways. J Interv Card Electrophysiol 2000; 4:605-10. [PMID: 11141207 DOI: 10.1023/a:1026565531895] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The exact nature of the reentry circuit for the atrioventricular nodal reentrant tachycardia (AVNRT) and particularly the concept and role of the upper and lower common pathways is not well defined. Although it is well accepted that the His-Purkinje system and the ventricles are not an essential part of the tachycardia circuit, controversy still exists as to whether the atria are essential components of the circuit. We describe a patient in whom the AVNRT perpetuated despite the spontaneous development of 2:1 anterograde and 3:2 retrograde block. To our knowledge, such a combination of electrophysiological phenomenon has not been previously reported. The electrophysiological basis of these observations and their clinical implications are discussed.
Collapse
Affiliation(s)
- B K Kantharia
- Section of Cardiac Electrophysiology and Pacing, Division of Cardiology, Department of Medicine, University of Massachusetts Medical Center, 55 Lake Avenue North, Worcester, Massachusetts 01565, USA.
| | | |
Collapse
|
49
|
Mewis C, Kühlkamp V, Bosch RF, Seipel L. Variable responsiveness of anterograde and retrograde fast pathway conduction to adenosine in patients with typical AV-nodal reentry tachycardia. Int J Cardiol 2000; 76:107-14. [PMID: 11104863 DOI: 10.1016/s0167-5273(00)00368-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Adenosine is known as a substance which depresses predominantly the slow pathway of the av-node. However, the effect of adenosine on the anterograde and retrograde fast pathway (FP) has not been studied in a large patient population. Ninety-one patients with inducible typical av-nodal reentrant tachycardias (AVNRT) were included. The clinically used dosage of 12 mg adenosine was administered subsequently as bolus injection during a constant atrial and ventricular pacing (500 ms) in all patients. Electrophysiological av-nodal parameters were determined. A higher responsiveness of the anterograde compared to the retrograde FP was observed: the majority of patients (76%) blocked anterogradely and 55% blocked retrogradely within the FP after the administration of 12 mg adenosine. Thirty-six percent of all patients revealed a differential behaviour to adenosine. Sixteen percent of all patients were completely resistant to adenosine (P=0.012). Electrophysiological parameters did not predict the responsiveness of the FP to adenosine. In patients with typical AVNRT the anterograde FP shows a higher sensitivity than the retrograde FP to adenosine. This might reflect an anatomical and/or functional distinction between anterograde and retrograde FP. The variable response to adenosine could be due to individual anatomical and electrophysiological heterogenity of the perinodal tissue and the av-node.
Collapse
Affiliation(s)
- C Mewis
- Department of Cardiology, University Hospital Tübingen, Tübingen, Germany.
| | | | | | | |
Collapse
|
50
|
Li YG, Bender B, Bogun F, Grönefeld G, Hohnloser SH. Location of the lower turnaround point in typical AV nodal reentrant tachycardia: a quantitative model. J Cardiovasc Electrophysiol 2000; 11:34-40. [PMID: 10695459 DOI: 10.1111/j.1540-8167.2000.tb00733.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Recent observations suggest that the circuit of AV nodal reentrant tachycardia (AVNRT) may extend down to the His bundle. The purpose of this study was to develop a quantitative model indicating the location of the lower turnaround point in AVNRT. METHODS AND RESULTS Slow pathway modification was performed in 70 patients with typical AVNRT. During sinus rhythm, ventricular pacing was performed with the AVNRT cycle length. During AVNRT, the HinitAinit interval was measured from initial His to the initial atrial deflection recorded in the His-bundle lead. During ventricular pacing, the HendAinit interval was measured from end of the His to the beginning of the atrial deflection. It was hypothesized that x reflects conduction time from the lower turnaround point to Ainit, whereas y reflects conduction time from the lower turnaround point to Hinit. Anterograde conduction during AVNRT and retrograde conduction during ventricular pacing were assumed to be identical if there was 1:1 retrograde conduction at the AVNRT cycle length. The following formulas describe the relation of the measured parameters: x - y = HinitAinit; and x + y = HendAinit. Resolving both formulas yields the unknown x and y: y = (HendAinit - HinitAinit)/2, x = (HendAinit + HinitAinit)/2. These criteria were present in 52 of 70 patients. The mean cycle length of AVNRT was 355 +/- 42 msec, mean HinitAinit was 54 +/- 27 msec, and mean HendAinit was 60 +/- 29 msec. Accordingly, in 20 of 52 patients, the lower turnaround point was located within the His bundle (y = -15.4 +/- 16.1 msec), in 3 of 52 it was in the nodal-His junctional area (y = 0), and in 29 of 52 it was above the His bundle (y = +12.7 +/- 10.3 msec). The HinitAinit interval was significantly longer (66 +/- 32 msec vs 47 +/- 20 msec; P = 0.02) and the HendAinit interval was significantly shorter (45 +/- 30 msec vs 69 +/- 24 msec; P = 0.004) when the first group was compared with the others. CONCLUSION In about 1 of 3 of patients with typical AVNRT, the lower turnaround point of the circuit is within the His bundle; in more than half of the patients it is above the His bundle. These data do not support the concept that all AVNRTs have an intranodal circuit, but are in accordance with the finding of longitudinal dissociation of the His bundle.
Collapse
Affiliation(s)
- Y G Li
- Department of Internal Medicine, J.W. Goethe University, Frankfurt, Germany
| | | | | | | | | |
Collapse
|