Anomalous Atrioventricular Excitation Research Articles

Contemporary Burden and Correlates of Symptomatic Paroxysmal Supraventricular Tachycardia.

BackgroundContemporary data about symptomatic paroxysmal supraventricular tachycardia (PSVT) epidemiology are limited. We characterized prevalence and correlates of symptomatic PSVT within a large healthcare delivery system and estimated national PSVT burden.Methods and ResultsWe identified adults with an encounter for potential PSVT between 2010 and 2015 in Kaiser Permanente Northern California, excluding those with prior known atrial fibrillation or atrial flutter. We adjudicated medical records, ECGs, and other monitoring data to estimate positive predictive values for targeted International Classification of Diseases (ICD), 9th and 10th Revisions codes in inpatient, emergency department, and outpatient settings. Combinations of diagnosis codes and settings were used to calculate PSVT prevalence, and PSVT correlates were identified using multivariable regression. We estimated national rates by applying prevalence estimates in Kaiser Permanente to 2010 US Census data. The highest positive predictive values included codes for “PSVT” in the emergency department (82%), “unspecified cardiac dysrhythmia” in the emergency department (27%), “anomalous atrioventricular excitation” as a primary inpatient diagnosis (33%), and “unspecified paroxysmal tachycardia” as a primary inpatient diagnosis (23%). Prevalence of symptomatic PSVT was 140 per 100 000 (95% confidence interval, 100–179) and was higher for individuals who were older, women, white or black, or who had valvular heart disease, heart failure, diabetes mellitus, lung disease, or prior bleeding. We estimate the national prevalence of symptomatic PSVT to be 168 per 100 000 (95% confidence interval, 120–215).ConclusionsSelected diagnostic codes in inpatient and emergency department settings may be useful to identify symptomatic PSVT episodes. We project that at least 0.168% of US adults experience symptomatic PSVT, and certain characteristics can identify people at higher risk.

Catheter ablation of accessory pathway: 14-year trends in utilization and complications in adults in the United States

BackgroundThe aim of this study was to determine the temporal trends in utilization of catheter ablation of accessory pathways in the United States. MethodsAll patients from the Nationwide Inpatient Sample (NIS) ≥18years of age with a primary diagnosis of anomalous atrioventricular excitation syndrome (International Classification of Diseases, Ninth Edition, Clinical Modification [ICD-9-CM] code 426.7) were included in the study. Patients who underwent catheter ablation were identified using ICD-9-CM procedure code 37.34. Patients with a concomitant diagnosis of atrial fibrillation, atrial flutter, atrial tachycardia or ventricular arrhythmias were excluded from the analysis. Annual hospital volume was identified using unique hospital identification number and was divided into tertiles for further analysis. ResultsA total of 11,601 catheter ablations for anomalous atrioventricular excitation syndrome were studied from 1998 to 2011. The mean length of stay was 1.8days (median 1day). The utilization trends of accessory pathway ablation have steadily declined from 3.9 ablation procedures/million US population in 1998–1999 to 2.5 ablation procedures/million US population in 2010–2011. The second tertile (adjusted OR 0.41; 95% CI 0.20–0.83, p=0.01) and third tertile (adjusted OR 0.39; 95% CI 0.18–0.85, p=0.02) of hospital volume were associated with reduction in cardiac complications as compared to first tertile of hospital volume. Advanced age (OR 1.02, 95% CI 1.01–1.04, p=0.002) was independent predictor of cardiac complications. There were no in-hospital deaths. ConclusionDespite decline in ablation trends, it still remains a relatively safe procedure associated with low morbidity and no mortality.

Clinical characteristics and outcomes in pregnant women with Ebstein anomaly at the time of delivery in the USA: 2003–2012

Ebstein anomaly is an uncommon congenital cardiac lesion that may be associated with cyanosis, arrhythmias and right heart dysfunction. Investigation into patient characteristics and outcomes in pregnant women with Ebstein anomaly has been limited. To characterize patient characteristics and clinical events for pregnant women with Ebstein anomaly during hospitalization for delivery in the USA; also, to determine the effect of Ebstein anomaly on maternal clinical outcomes and individual predictors of poor outcome at time of delivery. We screened the Healthcare Cost and Utilization Project's National Inpatient Sample for hospital admissions of pregnant women for delivery (vaginal or caesarean section) in the USA from 2003-2012, and identified a cohort of 7,850,381. Clinical characteristics and maternal outcomes were identified in those with and without Ebstein anomaly. The primary outcome of interest was major adverse cardiac events (MACE), a composite of in-hospital death, acute myocardial infarction, cerebrovascular events, embolic events, cardiac complications of labour and delivery heart failure or arrhythmia. Our study population consisted of 82 hospitalizations of pregnant women with Ebstein anomaly and 7,850,299 without. The Ebstein cohort more frequently had ostium secundum-type atrial septal defect and/or patent foramen ovale and anomalous atrioventricular excitation (P<0.001 for both). The MACE rate was significantly higher among Ebstein patients (P<0.001). Preterm delivery, postpartum haemorrhage and caesarean delivery occurred more frequently among the Ebstein cohort (19.5% vs 7.2%, 8.5% vs 2.8% and 47.6% vs 31.1%, respectively; P≤0.001). In a multivariable analysis, anomalous atrioventricular excitation (odds ratio [OR] 21.75, 95% confidence interval [CI] 1.03-457.91) and preterm delivery (OR 11.71, 95% CI 1.39-98.89) were associated with MACE among those with Ebstein anomaly. Pregnant women with Ebstein anomaly are at higher risk of MACE during pregnancy and delivery. Preterm delivery occurred more frequently in women with Ebstein anomaly.

Successive Myocardial Infarctions in a Patient with Mahaim Fiber Syndrome

A patient with Mahaim fiber syndrome suffered two acute myocardial infarctions during the last two years. Anomalous atrioventricular excitation was intermittent. Diagnosis of both anteroseptal and anterolateral electrocardiographic myocardial infarction could be made despite ventricular pre-excitation. These findings have not been previously published, to our knowledge.

ECG changes after cerebral stimulation. I. Anomalous atrioventricular excitation elicited by electrical stimulation of the mesencephalic reticular formation

Unipolar electrodes were stereotaxically implanted in the mesencephalic reticular formation of adult boxer dogs anesthetized with Surital sodium. Electrical stimulation (60 c.p.s. of alternating current) of a circumscribed area at the level of the pons produced an anomalous atrioventricular excitation similar to the WPW phenomenon observed in clinical medicine. Bilateral section of the vagosympathetic trunks had no effect on the production of this aberrant cardiac rhythm; however, it could no longer be elicited after section of the spinal cord at the level of the second cervical vertebra. These results demonstrate that the WPW-like complexes observed in this study are mediated exclusively by the sympathetic division of the antonomic nervous system. Electrical stimulation of the distal cut-end of the right vagosympathetic trunk, after the aberrant rhythm had been elicited by cerebral stimulation, abolished the abnormal response.

The specialized tissues of the heart; proceedings of a symposium on specialized tissues of the heart, August, 1960, Rio de Janeiro.

This slender volume assembles the proceedings of a symposium held at Rio de Janeiro in 1960. Among anatomical subjects considered were the evidence for direct conducting pathways from the sino-atrial to the atrioventricular node, for paranodal fibers and for an interatrial (Bachman) bundle; the contention that specialized conducting tissues do not exist in man; and an anatomical basis of anomalous atrioventricular excitation. Handsomely illustrated sections are presented on the developing heart as it is revealed by the electron microscope. The papers also include discussions of the interrelationship between ions and electrical activity in specialized tissues, the potassium and chloride permeability of Purkinje fibers, and the cellular electrophysiology of atrial tissue. And in the borderland between the electrical and anatomical disciplines, the growing conviction is emphasized that the capacity for activity is restricted to pacemaker tissue. Finally, in an excellent study employing a combination of histological and electrical techniques, the

Electrocardiographic and vectorcardiographic detection of heart disease in the presence of the pre-excitation syndrome (Wolff-Parkinson-White syndrome).

Excerpt It is well known that the electrocardiographic diagnosis of myocardial disease, particularly of myocardial infarction, in the presence of left bundle branch block (LBBB) is difficult. Howev...

Idiopathic hypertrophic subaortic stenosis: Clinical, hemodynamic and angiographic manifestations

The diagnosis of idiopathic hypertrophic subaortic stenosis, i.e., left ventricular hypertrophy producing severe obstruction to left ventricular outflow, has been established in fourteen patients. All had systolic murmurs, most prominent either at the mitral or tricuspid areas. Left ventricular systole was prolonged, resulting in paradoxical splitting of the second heart sound. Electrocardiograms showed either left ventricular hypertrophy or anomalous atrioventricular excitation, and roentgenograms demonstrated left atrial and ventricular enlargement without aortic dilatation. Left heart catheterization revealed systolic pressure gradients within the ventricle ranging from 40 to 185 mm. Hg, and localized the site of obstruction to the left ventricular outflow tract in every patient. The left ventricular pressure pulses exhibited a characteristic notch in early ventricular systole, and a striking rise during atrial contraction. Both the palpable and recorded peripheral arterial pressure pulses rose rapidly during early systole, unlike those in valvular aortic stenosis [6]. Left ventricular angiocardiograms demonstrated a markedly thickened ventricular wall obstructing the outflow tract of the left ventricle only during a portion of the cardiac cycle. At open operation in five patients the angiocardiographic interpretations were confirmed; in two patients the hypertrophied muscular ring was incised longitudinally to relieve the obstruction and the early clinical and hemodynamic results of this operation are encouraging. With the delineation of its clinical, hemodynamic, angiocardiographic and anatomic features, idiopathic hypertrophic subaortic stenosis emerges as a specific entity which can be distinguished preoperatively from discrete valvular and subvalvular aortic stenosis. Its recognition is important in selecting for operation patients with all forms of obstruction to left ventricular outflow and in planning the surgical procedure.

The ventricular gradient vector and related vectors

The concept of a mean vector with respect to time for a certain time interval is discussed. A simple method for determining the area vector for electrocardiographic cardiac complexes is presented, and the theoretical and practical advantages of its use are discussed. The ventricular gradient area difference vector is defined and is determined for the dog experiment of Wilson and associates, for two cases of right and two cases of left intermittent bundle branch block and for one case of intermittent anomalous atrioventricular excitation. It is pointed out that in each case this difference vector may be due to alteration of the lead fields or may be an indication of invalidity of Wilson's hypothesis.

Electrocardiographic criteria in the differential diagnosis of pre-excitation (Wolff-Parkinson-White syndrome) and arteriosclerotic heart disease.

THE electrocardiographic picture of prolonged QRS-complex duration with short PR interval was the subject of isolated reports1 , 2 until Wolff, Parkinson and White3 described the clinical syndrome of "bundle-branch block with short PR interval in healthy young people prone to paroxysmal tachycardia."Subsequent studies have demonstrated that premature ventricular excitation, not delayed conduction, prolongs QRS-complex duration. Block of neither the right nor the left bundle branch interferes with premature excitation, suggesting that the main bundles are not pathways for the premature impulse.Many synonyms for the Wolff–Parkinson–White syndrome have appeared. These include accessory-bundle syndrome,4 bundle-of-Kent syndrome,5 anomalous atrioventricular excitation,6 pre-excitation7 and . . .

Myocardial infarction in the Worlff-Parkinson-White syndrome: A method of vector analysis of ECG changes

The case presented is the third to be published with electrocardiograms recorded during anomalous atrioventricular excitation before and after myocardial infarction. It is proposed that there are seven possible components to ventricular depolarization during anomalous atrioventricular excitation after myocardial infarction. A method of vector analysis is presented which permits selective vectorial cancellation of these components when they are manifested in two or more separate electrocardiograms. The characteristics of the four components which form the basis for the recognition of myocardial infarction are described. The case presented is analyzed, and it is concluded that study of the ventricular depolarization loops for the electrocardiograms taken during anomalous atrioventricular excitation permits the recognition of the occurrence of an acute inferoseptal myocardial infarction. Analysis of the ST-T waves leads to the same conclusion. Analysis of an electrocardiogram taken during normal atrioventricular excitation appears to confirm the conclusions.

The diagnosis of myocardial infarction in patients with anomalous atrioventricular excitation (Wolff-Parkinson-White Syndrome)

Anomalous atrioventricular excitation produces changes in the QRS complex which simulate myocardial infarction, and it conceals the presence of myocardial infarction by preventing the development of the QRS abnormalities which are diagnostic of this lesion. The anomalous order of ventricular excitation also produces changes in the S-T segments and T waves, which are characteristically unstable in this syndrome. Changes dependent on physiologic, or other, unknown influences, commonly occur. It is not possible to distinguish such changes from those which follow infarction of the myocardium. Moreover, similar S-T segment and T wave abnormalities occur with other types of injury and with other pathologic states, or may occur following the administration of certain drugs. These signs, then, cannot be considered reliable evidence of myocardial infarction. All these facts are important in the management of patients whose electrocardiograms display anomalous atrioventricular excitation. Error can be avoided only if great care is taken to recognize anomalous conduction, and then to refrain from making a diagnosis of infarction unless normally conducted beats ∗ occur, or can be induced. Carotid sinus stimulation, atropine, quinidine, and amyl nitrite, separately, or in combination, usually suffice to restore normal conduction. Failure with a given drug or measure on one occasion may be followed by success on another. The amount and rapidity of administration of drugs may be varied. The effect of digitalis in facilitating the appearance of, or in perpetuating the continuance of the anomalous mechanism, may explain failure to induce normal conduction in some cases. When feasible, efforts to convert the cardiac mechanism should be attempted before digitalis is administered, or, when it can be done without harm to the digitalized patient, the drug should be omitted when it seems impossible to abolish anomalous conduction otherwise.

Wolff-Parkinson-White syndrome and paroxysmal tachycardia in infancy; report of a case.

The syndrome of anomalous atrioventricular excitation, more commonly known as the Wolff-Parkinson-White syndrome, is an electrocardiographic entity that has been the subject of much discussion in recent years. Up to the present, however, only a few cases have been reported of this condition in infants. This conduction defect seems to predispose the patient to attacks of paroxysmal tachycardia, which are of a more serious nature in infants than they usually are in adults. For these reasons, we wish to report a case of paroxysmal supraventricular tachycardia in a 4-month-old infant in whom the electrocardiogram made on cessation of the arrhythmia showed the presence of the Wolff-Parkinson-White syndrome. REPORT OF A CASE A 4-month-old baby girl, weighing 11 lb. 6 oz. (5.17 kg.), was brought to St. Vincent's Hospital at 10 a. m., May 2, by her parents, because of weakness, pallor, and failure to nurse. Until 24 hours earlier, she

Myocardial infarction in Wolff-Parkinson-White syndrome

The electrocardiographic confirmation of myocardial infarction in the presence of the Wolff-Parkinson-White syndrome has been difficult to obtain. 5,6,10 The bundle branch block configuration, it is maintained, will obscure the pattern of myocardial necrosis. The purpose of this paper is to present a case where the electrocardiogram was diagnostic of infarction in the presence of anomalous atrioventricular conduction. This individual was known to have had the Wolff-Parkinson-White syndrome for at least five years before the onset of a classical clinical episode of acute myocardial infarction. Fortuitously, in one of the tracings a spontaneous change occurred from anomalous atrioventricular excitation to periods of normal conduction. It was during these latter phases that unequivocal electrocardiographic evidence of myocardial infarction was noted. No case with a similar electrocardiographic pattern has been found in a thorough search of the literature. The syndrome of short P-R interval and prolonged QRS complex was first defined as a clinical entity by Wolff, Parkinson, and White 1 in 1930. Wolferth and Wood 2 and Holzmann and Scherf 3 independently postulated the existence of an accessory pathway between the atria and ventricles, similar to the so-called bundle of Kent, as explaining the electrocardiographic findings. Originally, Wolff, Parkinson, and White believed they were dealing with the effect of excessive vagal tone. There have been others 4 who offered evidence that the syndrome had a physiologic basis. This syndrome has been considered benign except for the attendant dangers of recurring attacks of paroxysmal tachycardia.

Anomalous Atrioventricular Excitation Produced by Catheterization of the Normal Human Heart

During the withdrawal of a catheter-electrode through the right ventricle of 2 normal subjects the electrogram displayed briefly a short P-R interval and an aberrant QRS. In the simultaneously recorded standard lead, the phenomenon simulated what is seen in the Wolff-Parkinson-White syndrome. The findings are presented in support of the physiologic, rather than anatomic, explanation for anomalous atrioventricular excitation.

Modification of the electrocardiogram of myocardial infarction by anomalous atrioventricular excitation (Wolff-Parkinson-White syndrome): Report of a case

The difficulty in occasional instances of differentiating myocardial infarction from anomalous atrioventricular excitation (Wolff-Parkinson-White syndrome) has been noted by Levine and Beeson, 1 Palatucci and Knighton, 2 Eichert, 3 and Missal, Wood, and Leo. 4 The paroxysmal tachycardia which occurs so regularly with anomalous excitation may produce chest discomfort which may be mistaken for the pain of infarction, and the electrocardiogram of anomalous excitation may also cause confusion. Fischer, 5 Zoll and Sachs, 23 Goldbloom and Dumanis, 6 and Rinzler and Travell 24 have reported cases of the coexistence of the two conditions. In these cases electrocardiograms were not recorded during periods when the anomalous excitation reverted to normal excitation, so that there is no comparison between the two, and the effect of anomalous excitation on the electrocardiogram of myocardial infarction cannot be determined. In the case which is the basis of the present discussion there is definite evidence of the coexistence of the two conditions, and electrocardiograms were recorded shortly after infarction showing both normal and anomalous excitation. These electrocardiograms reveal the fact that anomalous atrioventricular excitation may obscure some of the diagnostic electrocardiographic signs of infarction, in this case, the Q wave. During normal excitation the electrocardiograms showed the characteristic Q 2 and Q 3 of posterior wall infarction. At other times, however, during anomalous excitation the Q 2 and Q 3 were absent, and the initial portions of QRS 2 and QRS 3 were small R waves.

Septal infarction with complete heart block and intermittent anomalous atrioventricular excitation (wolff-parkinson-white syndrome): Histologic demonstration of a right lateral bundle

A proved case of myocardial infarction involving the interventricular septum showed complete heart block and intermittent anomalous atrioventricular excitation (short P-R interval, prolonged QRS complex). At necropsy an accessory right lateral bundle was found bridging the atrioventricular groove at the right posterolateral aspect of the heart. In this case anomalous ventricular excitation obliterated the QRS changes of posterior myocardial infarction, but the RS-T and T-wave changes persisted.

Sequence of ventricular stimulation and contraction in a case of anomalous atrioventricular excitation

1. 1. In a case of intermittent anomalous atrioventricular excitation it was found that the interval from the beginning of the P to the end of the QRS was shorter with the anomalous than with the normal beats. 2. 2. These and other data are interpreted to mean that depolarization of the ventricles was mediated entirely through an accessory pathway in the right ventricle, and that there was no conduction through the normal A-V conduction system when the QRS complexes were anomalous. 3. 3. Considerable delay in ejection of the left ventricle compared to the right occurred when the P-R interval was short. 4. 4. It is suggested that in different individuals with the syndrome, and sometimes in the same individual, variations in the relative amounts of ventricular muscle excited by impulses reaching it through the normal pathway on the one hand and through an accessory bundle or bundles on the other, readily explains many observations which have heretofore been regarded as conflicting.

TONIC AND REFLEX FUNCTIONS OF MEDULLARY SYMPATHETIC CARDIOVASCULAR CENTERS

TONIC AND REFLEX FUNCTIONS OF MEDULLARY SYMPATHETIC CARDIOVASCULAR CENTERS

SHORT P-R INTERVAL ASSOCIATED WITH PROLONGATION OF QRS COMPLEX; A CLINICAL STUDY DEMONSTRATING INTERESTING VARIATIONS

Article1 July 1944SHORT P-R INTERVAL ASSOCIATED WITH PROLONGATION OF QRS COMPLEX; A CLINICAL STUDY DEMONSTRATING INTERESTING VARIATIONSOSCAR A. PALATUCCI, JAMES E. KNIGHTONOSCAR A. PALATUCCISearch for more papers by this author, JAMES E. KNIGHTONSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-21-1-58 SectionsAboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail ExcerptBecause of the recent interest in the syndrome of the short P-R interval associated with a prolonged QRS complex, without organic heart disease (Wolff-Parkinson-White syndrome), as evinced by the publication of several articles on this subject in the past two years, it is desired to add four other cases to the rapidly growing list of reports. In accordance with the sex predominance previously reported1all of these have occurred in healthy, young male subjects. Other characteristics include absence of definite organic heart disease, slurring of the initial ventricular deflection, a peculiar susceptibility to attacks of paroxysmal tachycardia, either supraventricular or...Bibliography1. BUTTERWORTHPOINDEXTER JSCA: Short P-R interval associated with a prolonged QRS complex, Arch. Int. Med., 1942, lxix, 437. CrossrefGoogle Scholar2. BISHOP LF: Bundle branch block with short P-R interval in individuals without organic heart disease: case report with review of literature, Am. Jr. Med. Sci., 1937, cxciv, 794. CrossrefGoogle Scholar3. HUNTERPAPPPARKINSON ACJ: The syndrome of short P-R interval, apparent bundle branch block, and associated paroxysmal tachycardia, Brit. Heart Jr., 1940, ii, 107. CrossrefGoogle Scholar4. WOLFERTHWOOD CCFC: The mechanism of production of short P-R intervals and prolonged QRS complexes in patients with presumably undamaged hearts: hypothesis of an accessory pathway of auriculo-ventricular conduction (Bundle of Kent), Am. Heart Jr., 1933, viii, 297. CrossrefGoogle Scholar5. WOLFERTHWOOD CCFC: Further observations on the mechanism of the production of a short P-R interval in association with prolongation of the QRS complex, Am. Heart Jr., 1941, xxii, 450. CrossrefGoogle Scholar6. HARTWELLBURRETTGRAYBIELWHITE ASJBAPD: The effect of exercise and of four commonly used drugs on normal human electrocardiogram, with particular reference to T wave changes, Jr. Clin. Invest., 1942, xxi, 409. CrossrefGoogle Scholar7. SPRAGUE HB: Modern concepts of cardiovascular disease, 1941, x, 10. Google Scholar8. FOXTRAVELLMOLOFSKY TTJL: Action of digitalis on conduction in the syndrome of short P-R interval and prolonged QRS complex, Arch. Int. Med., 1943, lxxi, 206. CrossrefGoogle Scholar9. LEVINEBEESON SAPB: The Wolff-Parkinson-White syndrome, with paroxysms of ventricular tachycardia, Am. Heart Jr., 1941, xxii, 401. CrossrefGoogle Scholar This content is PDF only. To continue reading please click on the PDF icon. Author, Article, and Disclosure InformationAffiliations: *Received for publication March 27, 1943. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Cited byMimics of ventricular tachycardia associated with the W-P-W syndromeWolff-Parkinson-White syndromeDie Rhythmusstörungen des Herzens (einschließlich der intramuralen Leitungsstörungen und des Alternans)The Wolff-Parkinson-White syndrome associated with paroxysmal ventricular tachycardiaA case of Wolff-Parkinson-White syndrome with paroxysmal ventricular tachycardiaThe effect of atropine on the cardiac mechanism in anomalous atrioventricular conductionVentricular Tachycardia during Cardiac Catheterization of Patient with Wolff-Parkinson-White SyndromeModification of the electrocardiogram of myocardial infarction by anomalous atrioventricular excitation (Wolff-Parkinson-White syndrome)The electrocardiographic diagnosis of acute myocardial infarction in the presence of the Wolff-Parkinson-White syndromeWolff-Parkinson-White syndrome 1 July 1944Volume 21, Issue 1Page: 58-69KeywordsCardiovascular therapyTachycardia ePublished: 1 December 2008 Issue Published: 1 July 1944 PDF downloadLoading ...