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Lee P. Editorial to irrigated contact-force sensing catheter may be beneficial for redo ablation of slow-fast atrioventricular nodal reentrant tachycardia in pediatric and adolescent patients. J Arrhythm 2024; 40:404-405. [PMID: 38939792 PMCID: PMC11199847 DOI: 10.1002/joa3.13015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 02/20/2024] [Indexed: 06/29/2024] Open
Affiliation(s)
- Pi‐Chang Lee
- Department of PediatricsTaichung Veterans General HospitalTaichung CityTaiwan
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Nakano M, Kondo Y, Kajiyama T, Nakano M, Ito R, Kitagawa M, Sugawara M, Chiba T, Ryuzaki S, Yoshino Y, Komai Y, Takanashi Y, Kobayashi Y. Junctional rhythm during cryoablation for typical atrioventricular nodal reentrant tachycardia. J Cardiovasc Electrophysiol 2023; 34:1665-1670. [PMID: 37343063 DOI: 10.1111/jce.15979] [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: 03/05/2023] [Revised: 05/27/2023] [Accepted: 06/11/2023] [Indexed: 06/23/2023]
Abstract
INTRODUCTION Cryoablation is being used as an alternative to radiofrequency (RF) ablation for atrioventricular nodal reentrant tachycardia (AVNRT) owing to the lower risk of atrioventricular block (AVB) compared to RF ablation. Junctional rhythm often occurs during successful application of RF ablation for AVNRT. In contrast, junctional rhythm has rarely been reported to occur during cryoablation. This retrospective study evaluated the characteristics of junctional rhythm during cryoablation for typical AVNRT. METHODS AND RESULTS This retrospective study included 127 patients in whom successful cryoablation of typical AVNRT was performed. Patients diagnosed with atypical AVNRT were excluded. Junctional rhythm appeared during cryofreezing in 22 patients (17.3%). These junctional rhythms appeared due to cryofreezing at the successful site in the early phase within 15 s of commencement of cooling. Transient complete AVB was observed in 10 of 127 patients (7.9%), and it was noted that atrioventricular conduction improved immediately after cooling was stopped in these 10 patients. No junctional rhythm was observed before the appearance of AVB. No recurrence of tachycardia was confirmed in patients in whom junctional rhythm occurred by cryofreezing at the successful site. CONCLUSION Occurrence of junctional rhythms during cryoablation is not so rare and can be considered a criterion for successful cryofreezing. Furthermore, junctional rhythm may be associated with low risk of recurrent tachycardia.
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Affiliation(s)
- Masahiro Nakano
- Department of Advanced Cardiorhythm Therapeutics, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Yusuke Kondo
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Takatsugu Kajiyama
- Department of Advanced Cardiorhythm Therapeutics, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Miyo Nakano
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Ryo Ito
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Mari Kitagawa
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Masafumi Sugawara
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Toshinori Chiba
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Satoko Ryuzaki
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Yutaka Yoshino
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Yuya Komai
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Yukiko Takanashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
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Bun SS, Wedn AM, Taher A, Taghji P, Squara F, Hasni K, De Zuloaga C, Ferrari E. Slow pathway elimination using antegrade conduction improvement with fast atrial pacing during AVNRT radiofrequency ablation: a proof-of-concept study. Acta Cardiol 2021; 77:524-531. [PMID: 34412553 DOI: 10.1080/00015385.2021.1965355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Radiofrequency (RF) ablation of slow pathway (SP) is usually performed in sinus rhythm while monitoring the occurrence of a slow junctional rhythm (JR). JR although sensitive, is not specific for elimination of SP conduction. Our objective was to prospectively evaluate feasibility and safety of SP elimination using fast atrial rate pacing (FAP) during RF delivery. METHODS Consecutive patients admitted for atrioventricular nodal re-rentrant tachycardia (AVNRT) ablation were included. The rate of proximal coronary sinus (CS) pacing was set to a value constantly yielding antegrade SP conduction, while carefully monitoring the AH interval. RF delivery (at the lower part of Koch's triangle) was considered successful if the AH shortened ≥ 14 ms or if transition from Wenckebach (WK) periods to a 1:1 conduction occurred. RESULTS 24 patients were included (54 ± 20 y). Typical AVNRT was induced in all (cycle length 349 ± 83 ms). RF delivery during CS pacing (335 ± 73 ms) led to AH shortening by 51 ± 25 ms in 13 patients. In 10 patients, a transition from 3:2 or 4:3 WK periods to 1:1 conduction occurred during the successful pulse. In one patient, atrial fibrillation was systematically induced during FAP, requiring conventional ablation. Non-inducibility, and SP conduction disappearance was obtained in all patients. No patient developed AV block. After a follow-up of 12 ± 3 months, no recurrences were observed. CONCLUSION SP ablation using FAP during RF delivery allows direct visualisation of its disappearance. In our cohort of patients, this technique was feasible without safety compromise.
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Wegner FK, Habbel P, Schuppert P, Frommeyer G, Ellermann C, Lange PS, Leitz P, Köbe J, Wasmer K, Eckardt L, Dechering DG. Predictors of AVNRT Recurrence After Slow Pathway Modification. Int Heart J 2021; 62:72-77. [PMID: 33455989 DOI: 10.1536/ihj.20-463] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Atrioventricular nodal reentry tachycardia (AVNRT) is the most common regular supraventricular tachycardia (SVT). Slow pathway modification (SPM) is the accepted first line treatment with reported success rates around 95%. Information regarding possible predictors of AVNRT recurrence is scarce.Out of 4170 consecutive patients with SPM in our department from 1993-2018, we identified 78 patients (1.9%) receiving > 1 SPM (69% female, median age 50 years) with a recurrence of AVNRT after a successful SPM. We matched these patients for age, gender and number of radiofrequency applications during first SPM with 78 patients who received one successful SPM in our center without AVNRT recurrence. Both groups were analyzed for possible predictors of a recurrence of AVNRT during long-term follow-up. The recurrence group contained a significantly lower proportion of patients with an occurrence of junctional beats during SPM (69% versus 89%, P = 0.006). Moreover, significantly more cases of previously diagnosed atrial fibrillation/tachycardia (AF/AT; 21% versus 5%, P = 0.007) and inducible AF/AT during electrophysiology study (23% versus 6%, P = 0.006) were present in the recurrence group. While more than half of patients had a recurrence within the first year, in 20% symptoms reappeared ≥ 4 years after ablation.In a small percentage of patients, AVNRT recurs after an initially successful ablation. Interestingly, these patients had significantly fewer junctional beats during ablation and a higher rate of other (inducible) arrhythmias. AVNRT recurrence spanned a considerable timeframe and should remain a differential diagnosis, even years after ablation.
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Affiliation(s)
- Felix K Wegner
- Department of Cardiology II - Electrophysiology, University Hospital Muenster
| | - Pia Habbel
- Department of Cardiology II - Electrophysiology, University Hospital Muenster
| | - Piet Schuppert
- Department of Cardiology II - Electrophysiology, University Hospital Muenster
| | - Gerrit Frommeyer
- Department of Cardiology II - Electrophysiology, University Hospital Muenster
| | - Christian Ellermann
- Department of Cardiology II - Electrophysiology, University Hospital Muenster
| | - Philipp S Lange
- Department of Cardiology II - Electrophysiology, University Hospital Muenster
| | - Patrick Leitz
- Department of Cardiology II - Electrophysiology, University Hospital Muenster
| | - Julia Köbe
- Department of Cardiology II - Electrophysiology, University Hospital Muenster
| | - Kristina Wasmer
- Department of Cardiology II - Electrophysiology, University Hospital Muenster
| | - Lars Eckardt
- Department of Cardiology II - Electrophysiology, University Hospital Muenster
| | - Dirk G Dechering
- Department of Cardiology II - Electrophysiology, University Hospital Muenster
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Impact of Radiofrequency Ablation and Antiarrhythmic Medications on the Quality of Life of Patients with Supraventricular Tachycardias: Preliminary Validation of the Greek Version of the Umea22 (U22) Questionnaire. BIOMED RESEARCH INTERNATIONAL 2018; 2018:3059478. [PMID: 30402470 PMCID: PMC6198555 DOI: 10.1155/2018/3059478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 06/16/2018] [Accepted: 09/24/2018] [Indexed: 12/03/2022]
Abstract
Objective This study aims to (i) translate, culturally adapt, and preliminarily validate the arrhythmia-specific Umea22 (U22) questionnaire and (ii) assess the impact of radiofrequency (RF) ablation and medical treatment on the quality of life of patients with supraventricular tachycardias (SVTs). Methods A total of 140 patients with atrioventricular nodal re-entry tachycardia (AVNRT) and atrioventricular re-entry tachycardia (AVRT) were enrolled in the study. Of these, 100 patients underwent RF ablation (group A) and 40 patients were managed with antiarrhythmic medications (group B). Health-related quality of life (HRQoL) was assessed for both groups using the Short Form-36 Health Survey (SF-36) and the arrhythmia-specific Umea22 (U22) questionnaire at baseline and 3-month follow-up. Exploratory and confirmatory factor analyses were performed to assess the validity of the U22 questionnaire. Univariate comparisons of HRQoL scores between study timepoints and multivariate regression analyses adjusting for baseline confounders were conducted. Results The factor analysis of the U22 questionnaire yielded a six-factor model (“burden of spells”; “heart contractility”; “character of spells”; “general/non-specific feeling”; “other specific somatic symptoms”; “fear”) with acceptable fit results. Patients of group A showed significant improvement in all SF-36 and U22 scores at 3 months' follow-up compared to baseline (all p<0.05). Patients of group B presented deterioration of the total SF-36 score (p=0.001) and improvement of certain U22 measures, namely, well-being (p=0.004), heartbeat speed, and intensity during arrhythmia spells (p<0.0001 for both measures) at 3 months' follow-up, compared to baseline. Employment status, male sex, and urban residence emerged as important predictors. Conclusion The Greek version of the U22 questionnaire is a valid tool to assess SVT-related symptoms. RF ablation appears to exert more pronounced beneficial outcomes on HRQoL of patients with SVTs compared to medical treatment. Prompt referral of patients with SVTs to specialist centers may favorably affect their quality of life and should be encouraged.
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Nakano M, Ueda M, Kondo Y, Hayashi T, Nakano M, Miyazawa K, Ishimura M, Kobayashi Y. Shortening of the atrial-His bundle interval during atrial pacing as a predictor of successful ablation for typical atrioventricular nodal re-entrant tachycardia. Europace 2018; 20:654-658. [PMID: 28520908 DOI: 10.1093/europace/eux100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 03/25/2017] [Indexed: 11/14/2022] Open
Abstract
Aims Shortening of the atrial-His bundle (AH) interval during the sinus rhythm is occasionally observed after slow pathway ablation for atrioventricular nodal re-entrant tachycardia (AVNRT). In addition, high-rate atrial pacing is useful for avoiding atrioventricular block. We hypothesized that shortening of the AH interval during slow pathway ablation under high-rate atrial pacing would lead to successful ablation of typical AVNRT. Methods and results This retrospective study included 37 patients in whom successful ablation of typical AVNRT was performed under atrial pacing. The AH interval was measured immediately before the first radiofrequency (RF) application and immediately after the last RF application, prior to the first induction. Twenty-five of 37 patients achieved procedural success at the first induction (i.e. successful group). No patients developed a prolonged AH interval or atrioventricular block. The AH interval was shortened by an average of 14.6 ± 7.7 and 1.8 ± 1.2 ms in the successful and other patient groups, respectively (P < 0.01). An AH interval decrease of > 10 ms was observed in 23 of 27 (85%) patients in the successful group, whereas all other patients had an AH interval decrease of < 5 ms. Conclusion Shortening of the AH interval during high-rate atrial pacing is a predictor of the successful ablation for typical AVNRT.
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Affiliation(s)
- Masahiro Nakano
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan
| | - Marehiko Ueda
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan
| | - Yusuke Kondo
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan
| | - Tomohiko Hayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan
| | - Miyo Nakano
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan
| | - Kazuo Miyazawa
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan
| | - Masayuki Ishimura
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan
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Abstract
OPINION STATEMENT Our approach to the ablation of atrioventricular nodal reciprocating tachycardia (AVNRT), the most common supraventricular tachycardia, is as follows: We first attempt ablation in the right atrial posteroseptum anterior to the coronary sinus ostium with a 4-mm non-irrigated tip catheter. If ablation within the triangle of Koch is unsuccessful with radiofrequency (RF), we switch to cryoablation and target a more superior (mid septal) region. We also utilize cryoablation if RF ablation produces transient VA block (absence of retrograde conduction during junctional rhythm) or a fast junctional rhythm (<350 msec). If cryoablation were to fail, or is not available, we would then suggest ablation within the coronary sinus targeting the roof (2-4 cm from the os) using a 3.5-mm irrigated tip catheter. If tachycardia were still inducible despite these measures, we would then proceed with transseptal puncture (given our greater experience with this over a retrograde aortic approach) and perform RF ablation along the posteroseptal left atrium and inferoseptal mitral annulus utilizing an irrigated tip catheter. In our experience, cryoablation reliably results in elimination of the slow pathway. The only left atrial ablation for AVNRT at our institution in the past year was performed because a patent foramen ovale allowed for rapid left atrial access, facilitating left atrial ablation of the slow pathway.
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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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Alihanoglu YI, Yildiz BS, Kilic DI, Evrengul H, Kose S. Clinical and electrophysiological characteristics of typical atrioventricular nodal reentrant tachycardia in the elderly - changing of slow pathway location with aging. Circ J 2015; 79:1031-6. [PMID: 25739340 DOI: 10.1253/circj.cj-14-1320] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The aim of this study was to retrospectively evaluate the clinical and electrophysiological characteristics of elderly patients with typical atrioventricular nodal reentrant tachycardia (AVNRT), and to assess the acute safety and efficacy of slow-pathway radiofrequency (RF) ablation in this specific group of patients. METHODS AND RESULTS The present study retrospectively included a total of 1,290 patients receiving successful slow-pathway RF ablation for typical slow-fast AVNRT. Patients were divided into 2 groups: group I included 1,148 patients aged <65 years and group II included 142 patients aged >65 years. The required total procedure duration and total fluoroscopy exposure time were significantly higher in group II vs. group I (P=0.005 and P=0.0001, respectively). The number of RF pulses needed for a successful procedural end-point was significantly higher in group II than in group I (4.4 vs. 7.2, P=0.005). While the ratio of the anterior location near to the His-bundle region was significantly higher in group II, the ratio of posterior and midseptal locations were significantly higher in group I (P=0.0001). The overall procedure success rates were similar. There was no significant difference between the 2 groups in respect of the complications rates. CONCLUSIONS This experience demonstrates that RF catheter ablation, targeting the slow pathway, could be considered as first-line therapy for typical AVNRT patients older than 65 years as well as younger patients, as it is very safe and effective in the acute period of treatment.
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Clinical and electrophysiological characteristics of the patients with relatively slow atrioventricular nodal reentrant tachycardia. J Interv Card Electrophysiol 2014; 40:117-23. [PMID: 24793102 DOI: 10.1007/s10840-014-9901-3] [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] [Received: 02/18/2014] [Accepted: 03/24/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The aim of this study is to retrospectively investigate clinical and electrophysiologic characteristics of typical AVNRT with relatively slow tachycardia rates below the average value compared to faster ones, in patients without structural heart disease. METHODS The present study retrospectively included a total of 1,150 patients receiving successful slow-pathway radio frequency ablation for typical slow-fast AVNRT. Patients were divided into two groups according to their tachycardia cycle length: group I included 1,018 patients with tachycardia cycle length < 400 msn and group II included 132 patients with cycle length > 400 msn. Patients with another form of arrhythmia other than typical AVNRT, the existence of structural heart disease, preexisting prolonged PR interval, history of clinically documented AF, and reasons capable of causing AF were accepted as exclusion criterias. RESULTS The patients in group II were older than those in group 1 (p=0.039), and male ratio was significantly higher in group II compared to group I (p=0.02). Wenckebach cycle length and AV node antegrade effective refractory period values before the RF ablation were significantly higher in group II compared to group I (p=0.0001 and 0.01, respectively). Right atrium effective refractory period values in both pre- and post-ablation period were significantly higher in group I compared to group II (p=0.0001 and 0.004, respectively). The existence of atrial vulnerability before ablation was significantly higher in group II compared to group I (p=0.007); however, there was no difference between the two groups in terms of atrial vulnerability after the ablation. In addition, while the ratio of anterior location as an ablation site near the His-bundle region was significantly higher in group II, the ratio of posterior location was significantly higher in group I (p=0.0001 for both). CONCLUSION Our experience demonstrates that clinical and electrophysiologic characteristics of AVNRT patients with relatively slower tachycardia rates were quite different compared to the faster AVNRT cases.
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Junctional rhythm occurring during AV nodal reentrant tachycardia ablation, is it different among Egyptians? Egypt Heart J 2013. [DOI: 10.1016/j.ehj.2013.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Bagherzadeh A, Keshavarzi T, Farahani MM, Goodarzynejad H. Determinants of immediate success for catheter ablation of atrioventricular nodal reentry tachycardia in patients without junctional rhythm. J Interv Card Electrophysiol 2013; 39:19-23. [DOI: 10.1007/s10840-013-9839-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2012] [Accepted: 09/02/2013] [Indexed: 11/24/2022]
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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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CHANG SHIHLIN, TAI CHINGTAI, LIN YENNJIANG, LO LIWEI, TUAN TACHUAN, UDYAVAR AMEYAR, TSAO HSUANMING, HSIEH MINGHSIUNG, HU YUFENG, CHIANG SHUOJU, CHEN YIJEN, WONGCHAROEN WANWARANG, UENG KWOCHANG, CHEN SHIHANN. Electrophysiological Characteristics and Catheter Ablation in Patients with Paroxysmal Supraventricular Tachycardia and Paroxysmal Atrial Fibrillation. J Cardiovasc Electrophysiol 2008; 19:367-73. [DOI: 10.1111/j.1540-8167.2007.01065.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Zhou Y, Guo J, Xu Y, Li X, Zhang P, Zhang H. Electrophysiologic characteristics and radiofrequency ablation of focal atrial tachycardia arising from para-Hisian region. Int J Clin Pract 2007; 61:385-91. [PMID: 17313604 DOI: 10.1111/j.1742-1241.2006.01203.x] [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] [Indexed: 11/26/2022] Open
Abstract
This study describes the electrophysiologic characteristics and radiofrequency ablation of focal atrial tachycardia (AT) arising from para-Hisian region in 14 (6.0%) patients of a consecutive series of 224 patients patients. Inverted or biphasic P wave in V(1) and uncharacteristic P wave in inferior leads were observed during tachycardia, suggesting that there isn't a characteristic P-wave morphology for para-Hisian AT. During electrophysiological study, tachycardia could be induced with programmed atrial extrastimuli in 11 patients while a spontaneous onset and offset with "warm-up and cool-down" phenomenon were seen in other three patients. Moreover, the tachycardias were sensitive to intravenous administration of adenosine triphosphate in all patients. On the basis of these findings, the mechanism is suggestive of triggered activity or micro-reentry, but automaticity cannot be conclusively excluded. Radiofrequency energy was delivered to the earliest site of atrial activation during AT. Ablating energy was carefully titrated, starting at 5 W and increasing gradually upto a maximum of 40 W, to achieve the ceasing of tachycardia. The long-term outcome was a 100% success rate in these 14 patients and there were no irreversible complications associated with ablation. Thus, the mapping and ablation of focal AT arising from para-Hisian region is safe and effective, delivery of radiofrequency energy in a titrated manner and continuous monitoring of atrioventricular (AV) conduction advocated to minimise the risk of damage to the anterograde AV conduction.
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Affiliation(s)
- Y Zhou
- Department of Cardiac Electrophysiology, People's Hospital, Peking University, Beijing, China
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Wang L, Li J, Yao R, Song S, Guo Z. Long-term follow-up of patients with P-R prolongation after catheter ablation of slow pathway for atrioventricular node re-entrant tachycardia. Arch Med Res 2005; 35:442-5. [PMID: 15610916 DOI: 10.1016/j.arcmed.2004.06.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2004] [Accepted: 06/11/2004] [Indexed: 11/26/2022]
Abstract
BACKGROUND Long-term impact of interval between P wave and R wave (P-R) prolongation on prognosis of patients with successful catheter ablation of slow atrioventricular nodal pathway was investigated. METHODS Among 436 patients undergoing slow-pathway ablation for atrioventricular node re-entrant tachycardia (AVNRT), 17 (3.9%) experienced permanent P-R prolongation. Ablation target sites where conduction block was induced were located in mid- or anteroseptum. Fast junctional rhythm with ventriculoatrial conduction block was observed in eight patients immediately before atrioventricular block. RESULTS Antegrade slow-pathway conduction was eliminated in 16 patients, and retrograde fast- and slow-pathway conduction was abolished in all patients. There was no recurrence of AVNRT after an average of 38 +/- 12 month follow-up. There was no deterioration of atrioventricular block in these patients. Average PR interval prior to hospital discharge and at the end of follow-up was 0.24 +/- 0.02 sec and 0.23 +/- 0.02 sec, respectively (p >0.05). Left ventricular ejection fraction remained unchanged in these patients (p >0.05). CONCLUSIONS Radiofrequency catheter ablation of slow pathway for AVNRT is associated with a small risk of atrioventricular block. PR prolongation after successful slow-pathway ablation is associated with benign prognosis.
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Affiliation(s)
- Lexin Wang
- Department of Cardiology, The Affiliated Hospital of Weifang Medical College, Weifang City, Shandong Province, People's Republic of China.
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Lee KT, Lee SH, Tai CT, Lee PC, Chiang CE, Lin YJ, Huang BH, Yuniadi Y, Lai WT, Chen SA. Effects of right bundle branch block during atrioventricular nodal reentrant tachycardia. Int J Cardiol 2005; 101:91-5. [PMID: 15860389 DOI: 10.1016/j.ijcard.2004.06.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2004] [Revised: 06/18/2004] [Accepted: 06/19/2004] [Indexed: 10/25/2022]
Abstract
BACKGROUND The significant role of bundle branch block during atrioventricular nodal reentrant tachycardia (AVNRT) is not clear. The purposes of this study were to study the effects of complete right bundle branch block (RBBB) on electrophysiological parameters during AVNRT and to define the significance of complete RBBB during AVNRT. METHODS AND RESULTS According to characteristics of electrocardiogram during sinus rhythm and AVNRT, 50 patients who underwent catheter ablation for slow-fast AVNRT were divided into three groups. Group I included 20 patients who had narrow QRS (< or = 110 ms) during sinus rhythm and AVNRT. Group II included 18 patients who had persistent RBBB (< or = 120 ms) during sinus rhythm and AVNRT. Group III included 12 patients who had narrow QRS during sinus rhythm, but they had narrow QRS and transient RBBB during AVNRT. The atrio-His (AH) interval (296+/-60 vs. 288+/-75 ms), His-ventricular (HV) interval (36+/-11 vs. 35+/-11 ms), His-atrial (HA) interval (72+/-24 vs. 71+/-28 ms), VA(HRA) interval (defined as the interval between the onset of ventricular depolarization and the onset of atrial activity of right high atrium; 34+/-24 vs. 37+/-25 ms), VA(CSO) interval (defined as the interval between the onset of ventricular depolarization and the onset of atrial activity of coronary sinus ostium; 13+/-28 vs. 26+/-23 ms) and tachycardia cycle length (TCL; 368+/-67 vs. 359+/-73 ms) during AVNRT were similar between group I and group II (all P > 0.05). In group III, the AH interval (255+/-81 vs. 246+/-83 ms), HV interval (44+/-5 vs. 42+/-11 ms), HA interval (66+/-19 vs. 70+/-15 ms), VA(HRA) interval (27+/-15 vs. 29+/-16 ms), VA(CSO) interval (23+/-25 vs. 21+/-25 ms) and TCL (322+/-76 vs. 316+/-77 ms) were not significantly different between AVNRT with narrow QRS and those with transient RBBB (all P > 0.05). CONCLUSIONS Persistent RBBB and transient RBBB have no significant effects on the electrophysiological parameters during AVNRT. These findings suggest that RBBB might not influence the conduction of lower common pathway or the circuit of AVNRT.
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Affiliation(s)
- Kun-Tai Lee
- Cardiovascular Research Center and Division of Cardiology, Veterans General Hospital-Taipei, Taiwan, R.O.C
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Estner HL, Ndrepepa G, Dong J, Deisenhofer I, Schreieck J, Schneider M, Plewan A, Karch M, Weyerbrock S, Wade D, Zrenner B, Schmitt C. Acute and Long-Term Results of Slow Pathway Ablation in Patients with Atrioventricular Nodal Reentrant Tachycardia-An Analysis of the Predictive Factors for Arrhythmia Recurrence. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2005; 28:102-10. [PMID: 15679639 DOI: 10.1111/j.1540-8159.2005.09364.x] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Predictors of atrioventricular nodal reentrant tachycardia (AVNRT) recurrence after radiofrequency ablation including the importance of residual slow pathway conduction are not known. The aim of this study was to report the acute and long-term results of slow pathway ablation in a large series of consecutive patients with AVNRT and to analyze the potential predictors of arrhythmia recurrence with a particular emphasis on the residual slow pathway conduction after ablation. METHODS The study included 506 consecutive patients with AVNRT (mean age 52.6 +/- 16 years, 315 women) who underwent slow pathway ablation using a combined electrophysiological and anatomical approach. The end point of ablation procedure was noninducibility of the arrhythmia. The primary end point of the study was the recurrence of AVNRT. RESULTS Acute success was achieved in 500 patients (98.8%). After ablation, 471 patients (93%) were followed up for a mean of 903 +/- 692 days. Of the 465 patients with successful ablation, 24 patients (5.2%) developed AVNRT recurrences during the follow-up. No significant differences in the cumulative rates of AVNRT recurrence were observed in groups with or without electrophysiological evidence of residual slow pathway conduction (P = 0.25, log-rank test). Multivariate analysis identified only age as an independent predictor of AVNRT recurrence (hazard ratio 0.96, 95% confidence interval 0.94-0.99, P = 0.004) with younger patients being at an increased risk for arrhythmia recurrence. CONCLUSIONS Our study demonstrated that only younger age, but not other clinical or electrophysiological parameters including residual slow pathway conduction predicted an increased risk for AVNRT recurrence after slow pathway radiofrequency ablation.
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Affiliation(s)
- Heidi Luise Estner
- Deutsches Herzzentrum München and 1. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
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Lee SH, Tai CT, Lee PC, Chiang CE, Cheng JJ, Ueng KC, Chen YJ, Hsieh MH, Tsai CF, Chiou CW, Yu WC, Kuo JY, Tsao HM, Lee KT, Chen SA. Electrophysiological Characteristics of Junctional Rhythm During Ablation of the Slow Pathway in Different Types of Atrioventricular Nodal Reentrant Tachycardia. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2005; 28:111-8. [PMID: 15679640 DOI: 10.1111/j.1540-8159.2005.09430.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Junctional rhythm (JR) is commonly observed during radiofrequency (RF) ablation of the slow pathway for atrioventricular (AV) nodal reentrant tachycardia. However, the atrial activation pattern and conduction time from the His-bundle region to the atria recorded during JR in different types of AV nodal reentrant tachycardia have not been fully defined. METHODS Forty-five patients who underwent RF ablation of the slow pathway for AV nodal reentrant tachycardia were included; 27 patients with slow-fast, 11 patients with slow-intermediate, and 7 patients with fast-slow AV nodal reentrant tachycardia. The atrial activation pattern and HA interval (from the His-bundle potential to the atrial recording of the high right atrial catheter) during AV nodal reentrant tachycardia (HA(SVT)) and JR (HA(JR)) were analyzed. RESULTS In all patients with slow-fast AV nodal reentrant tachycardia, the atrial activation sequence recorded during JR was similar to that of the retrograde fast pathway, and transient retrograde conduction block during JR was found in 1 (4%) patient. The HA(JR) was significantly shorter than the HA(SVT) (57 +/- 24 vs 68 +/- 21 ms, P < 0.01). In patients with slow-intermediate AV nodal reentrant tachycardia, the atrial activation sequence of the JR was similar to that of the retrograde fast pathway in 5 (45%), and to that of the retrograde intermediate pathway in 6 (55%) patients. Transient retrograde conduction block during JR was noted in 1 (9%) patient. The HA(JR) was also significantly shorter than the HA(SVT) (145 +/- 27 vs 168 +/- 29 ms, P = 0.014). In patients with fast-slow AV nodal reentrant tachycardia, retrograde conduction with block during JR was noted in 7 (100%) patients. The incidence of retrograde conduction block during JR was higher in fast-slow AV nodal reentrant tachycardia than slow-fast (7/7 vs 1/11, P < 0.01) and slow-intermediate AV nodal reentrant tachycardia (7/7 vs 1/27, P < 0.01). CONCLUSIONS In patients with slow-fast and slow-intermediate AV nodal reentrant tachycardia, the JR during ablation of the slow pathway conducted to the atria through the fast or intermediate pathway. In patients with fast-slow AV nodal reentrant tachycardia, there was no retrograde conduction during JR. These findings suggested there were different characteristics of the JR during slow-pathway ablation of different types of AV nodal reentrant tachycardia.
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Affiliation(s)
- Shih-Huang Lee
- Cardiovascular Research Center and Division of Cardiology, Department of Medicine, National Yang-Ming University, Veterans General Hospital-Taipei, Taiwan, ROC.
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Sugiyama A, Satoh Y, Ishida Y, Yoneyama M, Yoshida H, Hashimoto K. Pharmacological and electrophysiological characterization of junctional rhythm during radiofrequency catheter ablation of the atrioventricular node: possible involvement of neurotransmitters from autonomic nervous system. Circ J 2002; 66:696-701. [PMID: 12135141 DOI: 10.1253/circj.66.696] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Catheter ablation of the atrioventricular node (AVN) with radiofrequency current is closely associated with the short-term onset of a junctional rhythm. The origin of this rhythm was analyzed in Beagle dogs which were anesthetized with pentobarbital sodium. Atrioventricular (AV) conduction block was induced first using a standard catheter ablation technique for the AVN, so that the sinus automaticity could not override the junctional ectopy during the following energy delivery. The ablation catheter was kept in the initial position and the delivery of radiofrequency energy was repeated. The pattern of ECG changes suggests that the dominant pacemaker may shift from the distal portion of the AV junctional area to the proximal portion during the energy delivery. This enhanced junctional automaticity was suppressed by the beta-blocker esmolol, but was not affected by M-antagonist atropine. Moreover, the beta-agonist isoproterenol did not induce the same type of junctional tachycardia, but the pacemaker shift was induced by the increased sympathetic tone after transient asystole by ventricular overdrive pacing or acetylcholine administration. These results suggest that proximal portion of the AV junctional area has extremely slow pacemaker activity, but responds to locally released norepinephrine with an abrupt rise and fall in rate, resulting in a typical pattern of junctional tachycardia during the ablation of the AVN.
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Affiliation(s)
- Atsushi Sugiyama
- Department of Pharmacology, Yamanashi Medical University, Japan.
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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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Wagshal AB, Crystal E, Katz A. Patterns of accelerated junctional rhythm during slow pathway catheter ablation for atrioventricular nodal reentrant tachycardia: temperature dependence, prognostic value, and insights into the nature of the slow pathway. J Cardiovasc Electrophysiol 2000; 11:244-54. [PMID: 10749347 DOI: 10.1111/j.1540-8167.2000.tb01793.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Although accelerated junctional rhythm (AJR) is a known marker for successful slow pathway (SP) ablation sites, AJR may just be a regional effect of the anisotropic conduction properties of this area of the heart. We believe that detailed assessment of the AJR might provide insight into the SP specificity of this AJR and perhaps the nature of the SP itself. METHODS AND RESULTS Our ablation protocol consisted of 30-second, 70 degrees C temperature-controlled ablation pulses with assessment after each pulse. Serial booster ablations were performed at the original successful site and at least 2 to 3 nearby sites to assess for residual AJR after the procedure in 50 consecutive SP ablations. We defined three distinct patterns of AJR: continuous AJR that persisted until the end of energy delivery (group I, 25 patients); alternating or "stuttering" AJR that persisted throughout energy delivery (group II, 9 patients); and AJR that ended abruptly during energy delivery (group III, 16 patients). Mean ablation temperatures in the three groups was 57 degrees+/-5 degrees C, 54 degrees+/-5 degrees C, and 63 degrees+/-5 degrees C, respectively (P = 0.0002 for groups I and II vs group III). Ten of 34 (29%) patients in groups I and II ("low-temperature ablation") exhibited residual SP (jump and/or single echo beats) despite tachycardia noninducibility, and 25 of 34 (73%) patients had residual AJR during the booster ablations, but neither of these was seen in any group III patients. CONCLUSION Ablation temperature correlates with the pattern of AJR produced during SP ablation. That higher temperature lesions simultaneously abolish all SP activity as well as the focus of AJR suggests that this AJR is specific for the SP and is not a nonspecific regional effect.
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Affiliation(s)
- A B Wagshal
- Department of Cardiology, Soroka Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva, Israel.
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