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Cunn G, Willner J, John RM. Ablation of ectopic atrial foci for successful management of symptomatic bradycardia: A case series (bradycardia and ectopic atrial beats). Pacing Clin Electrophysiol 2023; 46:504-509. [PMID: 36660967 DOI: 10.1111/pace.14639] [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: 04/30/2022] [Revised: 08/18/2022] [Accepted: 11/21/2022] [Indexed: 01/21/2023]
Abstract
Atrial premature contractions (PACs) that block at the atrio-ventricular (AV) nodal level and occurring in a bigeminal frequency are recognized as a cause of symptomatic bradycardia. Appropriate suppression of the PACs often results in restoration of a regular rhythm with resolution of bradycardia-related symptoms. We report a series of three patients with non-conducted bigeminal PACs arising from the mitral annulus that resulted in symptomatic bradycardia and who were referred for consideration of cardiac pacing. Focal ablation suppressed PACs restoring a normal heart rate and resolution of symptoms without resorting to cardiac pacing.
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Affiliation(s)
- Gregory Cunn
- Department of Cardiology, Northshore University Hospital, Manhasset, New York, USA
| | - Jonathan Willner
- Department of Cardiology, Northshore University Hospital, Manhasset, New York, USA
| | - Roy M John
- Department of Medicine, Division of Cardiology, Stanford School of Medicine, Palo Alto, California, USA
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Wang Z, Ouyang J, Liang Y, Jin Z, Yang G, Liang M, Li S, Yu H, Han Y. Focal atrial tachycardia surrounding the anterior septum: strategy for mapping and catheter ablation. Circ Arrhythm Electrophysiol 2015; 8:575-82. [PMID: 25908691 PMCID: PMC4467584 DOI: 10.1161/circep.114.002281] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Accepted: 04/10/2015] [Indexed: 11/16/2022]
Abstract
Background— Focal atrial tachycardias (ATs) surrounding the anterior atrial septum (AAS) have been successfully ablated from the right atrial septum (RAS), the aortic cusps, and the aortic mitral junction. However, the strategy for mapping and ablation of AAS-ATs has not been well defined. Methods and Results— Of 227 consecutive patients with AT, 47 (20.7%; mean age, 56.3±11.6 years) with AAS-ATs were studied; among them, initial ablation was successful at RAS in only 5 of 14 patients and at noncoronary cusp (NCC) in 28 of 33 patients. In 45 of the 47 patients, the 46 of 48 AAS-ATs were eliminated at RAS in 8 patients, NCC in 35 patients (earliest activation time at NCC was later than that at RAS by 5–10 ms in 6 patients), and aortic mitral junction in 3 patients (all with negative P wave in lead aVL and positive P wave in the inferior leads), including 1 patient whose 2 ATs were eliminated separately from the NCC and the aortic mitral junction. Conclusions— Most of the ATs surrounding the AAS can be eliminated from within the NCC, which is usually the preferential ablation site. Ablation at the RAS and aortic mitral junction should be considered when supported by P-wave morphologies on surface ECG and results of activation mapping and ablation.
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Affiliation(s)
- Zulu Wang
- From the Department of Cardiology, Shenyang Northern Hospital, Shenyang, China (Z.W., Y.L., Z.J., G.Y., M.L., S.L., H.Y., Y.H.); and Department of Cardiology, Fuzhou General Hospital of Nanjing Command, Fuzhou, China (J.O.)
| | - Jinge Ouyang
- From the Department of Cardiology, Shenyang Northern Hospital, Shenyang, China (Z.W., Y.L., Z.J., G.Y., M.L., S.L., H.Y., Y.H.); and Department of Cardiology, Fuzhou General Hospital of Nanjing Command, Fuzhou, China (J.O.)
| | - Yanchun Liang
- From the Department of Cardiology, Shenyang Northern Hospital, Shenyang, China (Z.W., Y.L., Z.J., G.Y., M.L., S.L., H.Y., Y.H.); and Department of Cardiology, Fuzhou General Hospital of Nanjing Command, Fuzhou, China (J.O.)
| | - Zhiqing Jin
- From the Department of Cardiology, Shenyang Northern Hospital, Shenyang, China (Z.W., Y.L., Z.J., G.Y., M.L., S.L., H.Y., Y.H.); and Department of Cardiology, Fuzhou General Hospital of Nanjing Command, Fuzhou, China (J.O.)
| | - Guitang Yang
- From the Department of Cardiology, Shenyang Northern Hospital, Shenyang, China (Z.W., Y.L., Z.J., G.Y., M.L., S.L., H.Y., Y.H.); and Department of Cardiology, Fuzhou General Hospital of Nanjing Command, Fuzhou, China (J.O.)
| | - Ming Liang
- From the Department of Cardiology, Shenyang Northern Hospital, Shenyang, China (Z.W., Y.L., Z.J., G.Y., M.L., S.L., H.Y., Y.H.); and Department of Cardiology, Fuzhou General Hospital of Nanjing Command, Fuzhou, China (J.O.)
| | - Shibei Li
- From the Department of Cardiology, Shenyang Northern Hospital, Shenyang, China (Z.W., Y.L., Z.J., G.Y., M.L., S.L., H.Y., Y.H.); and Department of Cardiology, Fuzhou General Hospital of Nanjing Command, Fuzhou, China (J.O.)
| | - Haibo Yu
- From the Department of Cardiology, Shenyang Northern Hospital, Shenyang, China (Z.W., Y.L., Z.J., G.Y., M.L., S.L., H.Y., Y.H.); and Department of Cardiology, Fuzhou General Hospital of Nanjing Command, Fuzhou, China (J.O.)
| | - Yaling Han
- From the Department of Cardiology, Shenyang Northern Hospital, Shenyang, China (Z.W., Y.L., Z.J., G.Y., M.L., S.L., H.Y., Y.H.); and Department of Cardiology, Fuzhou General Hospital of Nanjing Command, Fuzhou, China (J.O.).
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Hai JJ, Chahal AA, Friedman PA, Vaidya VR, Syed FF, DeSimone CV, Nanda S, Brady PA, Madhavan M, Cha YM, McLeod CJ, Mulpuru S, Munger TM, Packer DL, Asirvatham SJ. Electrophysiologic characteristics of ventricular arrhythmias arising from the aortic mitral continuity-potential role of the conduction system. J Cardiovasc Electrophysiol 2015; 26:158-63. [PMID: 25425429 DOI: 10.1111/jce.12587] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Revised: 10/02/2014] [Accepted: 10/14/2014] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Catheter ablation of ventricular arrhythmia (VA) at the fibrous aortic mitral continuity (AMC) has been described, yet the nature of the arrhythmogenic substrate remains unknown. METHODS Procedural records of 528 consecutive patients undergoing ablation of VA at Mayo Clinic, Rochester, MN, were reviewed. The electrocardiographic and electrophysiologic characteristics of patients with successful ablation at the AMC were analyzed to characterize the underlying arrhythmogenic substrate. RESULTS Of the 21 patients (mean age 53.2 ± 13.4 years, 47.6% male) who underwent ablation of VA at the AMC with acute success, prepotentials (PPs) were found at the ablation sites preceding the ventricular electrogram (VEGM) during arrhythmias in 13 (61.9%) patients and during sinus rhythm in 7 (53.8%) patients. VAs with PPs were associated with a significantly higher burden of premature ventricular complexes (PVCs; 26.1 ± 10.9% vs. 14.9 ± 10.1%, P = 0.03), shorter VEGM to QRS intervals (9.0 ± 28.5 milliseconds vs. 33.1 ± 8.8 milliseconds, P = 0.03), lower pace map scores (8.7 ± 1.6 vs. 11.4 ± 0.8, P = 0.001), and a trend toward shorter V-H intervals during VA (32.1 ± 38.6 milliseconds vs. 76.3 ± 11.1 milliseconds, P = 0.06) as compared to those without PP. A strong and positive correlation was found between V-H interval and QRS duration during arrhythmia in those with PPs (B = 2.11, R(2) = 0.97, t = 13.7, P < 0.001) but not in those without PPs. CONCLUSION Local EGM characteristics and relative activation time of the His bundle suggest the possibility of conduction tissue as the origin for VA arising from the fibrous AMC. Specific identification and targeting of PPs when ablating VAs at this location may improve procedural success.
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Affiliation(s)
- Jo Jo Hai
- Division of Cardiology, Department of Medicine, Queen Mary Hospital, Hong Kong
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Hai JJ, Lachman N, Syed FF, Desimone CV, Asirvatham SJ. The anatomic basis for ventricular arrhythmia in the normal heart: what the student of anatomy needs to know. Clin Anat 2014; 27:885-93. [PMID: 24446306 DOI: 10.1002/ca.22362] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Accepted: 11/25/2013] [Indexed: 11/11/2022]
Abstract
The traditional route for teaching cardiac anatomy involves didactic instruction, cadaver dissections, and familiarization with the main structure and relationships of the cardiac chambers, valves, and vasculature. In contemporary cardiac electrophysiology, however, a very different view of anatomy is required including details rarely appreciated with a general overview. In this review, we discuss the critical advances in cardiac electrophysiology that were possible only because of understanding detailed anatomic relationships. While we briefly discuss the clinical relevance, we explain in depth the necessary structural information for the student of clinical anatomy. Interspersed through the text are boxes that highlight and summarize the critical pieces of knowledge to be borne in mind while studying the fascinating structural anatomy of the human heart.
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Affiliation(s)
- Jo Jo Hai
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
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Wang Z, Liu T, Shehata M, Liang Y, Jin Z, Liang M, Han Y, Amorn A, Liu X, Liu E, Chugh SS, Wang X. Electrophysiological characteristics of focal atrial tachycardia surrounding the aortic coronary cusps. Circ Arrhythm Electrophysiol 2011; 4:902-8. [PMID: 21985795 DOI: 10.1161/circep.111.965640] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Catheter ablation of atrial tachycardia (AT) arising near the coronary cusps has been reported in limited numbers of patients. We investigated the electrophysiological characteristics of these ATs in 22 consecutive patients. METHODS AND RESULTS This study included 22 patients (mean age ± SD, 53 ± 11 years; 86% female) with ATs arising near the aortic coronary cusps who underwent successful ablation. Activation mapping was performed during tachycardia to identify the earliest activation site. All patients achieved successful ablation through either a retrograde aortic (n=19) or a transseptal (n=3) approach. The successful ablation sites were located in the noncoronary cusp (NCC) (n=16), including 3 near the junction between the NCC and right coronary cusp. The remaining 6 cases were ablated from the left coronary cusp (LCC) (n=3) or the left atrium posterior to the LCC (n=3). For most tachycardias, there were distinctive P-wave morphological features recorded for each cusp location. Furthermore, analysis of the electrogram morphological features recorded during tachycardia at successful ablation sites revealed an atrial/ventricular (A/V) ratio >1 in 14 of 16 NCC ATs; the remaining 2, from the NCC near the junction with the right coronary cusp, showed an A/V ratio ≤ 1. At ablation sites in the LCC, the A/V ratio was <1 (4 of 6 patients) or 1 (remaining 2 patients). During a follow-up duration of 30 ± 13 months, all patients were free of arrhythmias without antiarrhythmic drugs. CONCLUSIONS ATs surrounding the aortic coronary cusps can be safely and effectively ablated, with good long-term outcomes. In addition to the P-wave morphological features, the A/V ratio of the local electrogram recording during tachycardia facilitated the localization of successful sites.
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Affiliation(s)
- Zulu Wang
- Department of Cardiology, Shenyang Northern Hospital, Shenyang, People's Republic of China
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