Anteroseptal Accessory Pathway Research Articles

Accuracy of algorithms to predict accessory pathway location in children with Wolff–Parkinson–White syndrome

ObjectiveThe aim of this study was to examine the accuracy in predicting pathway location in children with Wolff–Parkinson–White syndrome for each of seven published algorithms.Patients and interventionsECGs from 100 consecutive...

The left coronary cusp as an unusual location for accessory pathway ablation

The aortic valve borders the anterior part of the mitral annulus, which explains the usual absence of antrioventricular accessory pathway (AP) in this area (Figure 1A). However, few cases of AP ablation in the noncoronary cusp (NCC) have been reported. 1 Suleiman M. Powell B. Munger T. Asirvatham S. Successful cryoablation in the noncoronary aortic cusp for a left anteroseptal accessory pathway. J Interv Card Electrophysiol. 2008; 23: 205-211 Crossref PubMed Scopus (29) Google Scholar , 2 Suleiman M. Brady P. Asirvatham S. Friedman P. Munger T. The noncoronary cusp as a site for successful ablation of accessory pathways: electrogram characteristics in three cases. J Interv Card Electrophysiol. 2011; 22: 203-209 Google Scholar , 3 Tada H. Naito S. Nogami A. Taniguchi K. Successful catheter ablation of an anteroseptal accessory pathway from the noncoronary sinus of Valsalva. J Cardiovasc Electrophysiol. 2003; 14: 544-546 Crossref PubMed Scopus (49) Google Scholar We report here the first case of AP ablation in the left coronary cusp (LCC) and discuss its anatomic substrate.

Surgical Procedure for Right Anteroseptal Accessory Conduction Pathways in Wolff-Parkinson-White Syndrome.

In patients with Wolff-Parkinson-White syndrome, the right anteroseptal accessory conduction pathway is rare, and exists from the atrium to the ventricle in close anatomic proximity to the normal atrioventricular conduction system. Catheter ablation of this lesion is reported to interrupt atrioventricular node-His bundle conduction more easily than that of other lesions. At our institute, there were 10 patients with right anteroseptal accessory conduction pathway among 454 patients (2.2%) who underwent the surgical division of the accessory pathway. Our procedure involved the the endocardial approach with knife dissection and cryocoagulation. With the heart beating under normothermal cardiopulmonary bypass, delta wave disappearance was easily noted. Neither complete atrioventricular block nor recurrent conduction occurred. Cryoablation used by our endocardial surgical division, is a safe and accurate procedure.

3D Mapping for Guide RF Ablation of Accessory Pathways Close Proximity of Atrioventricular Node and His Bundle

Anteroseptal and parahisian accessory pathway (AP) in the vicinity of the atrioventricular node (AVN) and the bundle of His, are associated with a high risk of complete atrioventricular block (AVB) during transcatheter radiofrequency ablation (RFA). Electro anatomical 3D mapping may be applied to avoid AVN and His bundle and reduce radiation exposure. We report 2 cases of AP that close proximity to AVN and His bundle using 3D EnSite NavX system. The first case was 35 year old lady with anteroseptal AP that conduct biderectonally. The AP was 16 mm away from His bundle. Both antegrade and retrograde conduction could be abolished with RF energy by of 3D mapping guidance. The procedure time was 65 minutes and the fluoroscopy time was 18 minutes. The second case was 22 year-old man with parahissian AP that only antegrade conduction. The distance between AP and His was about 3–4 mm. The AP could be successfully ablated using 3D mapping guide. The procedure time was 95 minutes and the fluoroscopy time was 20 minutes. In conclusion: RFA for patients with AP that close proximity to AV node and His bundle using 3D mapping guide is a feasible and effective radical therapy. This technique may reduce the risk of total AV block and radiation exposure.

A Case of Left Ventricular Noncompaction Accompanying Fasciculo-Ventricular Accessory Pathway and Atrial Flutter

Left ventricular hypertrabeculation/noncompaction (LVHT) is an uncommon type of genetic cardiomyopathy characterized by trabeculations and recesses within the ventricular myocardium. Frequently associated arrhythmias included atrial fibrillation, ventricular arrhythmias, atrioventricular block, and Wolff-Parkinson-White syndrome. A 29-year-old male presented with palpitations and shortness of breath. The ECG showed pre-excitation and anteroseptal accessory pathway was suspected. The echocardiogram revealed prominent trabeculations and deep recesses in the left ventricles. The recesses were perfused by intraventricular flow. During the echocardiographic examination, tachycardia developed spontaneously. The ECG showed wide complex tachycardia and the QRS morphology was similar to that of sinus rhythm. An electrophysiologic study was performed. Decremental atrial pacing caused prolongation of both AH and AV intervals in parallel. The HV interval and the degree of preexcitation remained unchanged from both right atrial and coronary sinus pacing with atrial extrastimuli. The His bundle pacing failed to normalize the QRS width. A diagnosis of fasciculo-ventricular accessory pathway was made. Decremental pacing on the proximal coronary sinus area induced typical atrial flutter, which was identical to the clinical tachycardia. A line of block was made across the cavo-tricuspid isthmus (CTI). A rare presentation of LVHT with fasciculo-ventricular accessory pathway and atrial flutter was successfully treated with conventional CTI block.

A Simple and Accurate Algorithm for Localizing Accessory Pathways in Patients with Wolff-Parkinson-White Syndrome

Introduction: A new and simple algorithm is proposed for localizing accessory pathways (APs) using only the R/S ratio. Methods: This study consisted of 101 patients with a single anterogradely conducting AP on 12-lead ECG. R/S ratios in V1, V2 and aVF were analyzed. A new algorithm was developed by correlating the 12-lead ECG findings with successful ablation sites in the 40 initial patients. This algorithm was subsequently tested in the 61 residual patients. Results: Among 61 patients, all 37 patients with left free wall APs showed the R/S ratio in V1 ≥0.5 (sensitivity 100%). Left anterior and lateral APs were associated with the R/S ratio in aVF ≥1 (sensitivity 97%). If the R/S ratio in V1 was <0.5 and the R/S ratio in V2 was ≥0.5, the AP location was midseptal or posteroseptal (sensitivity 100%). If the R/S ratio in both V1 and V2 was <0.5, it was right free wall or right anteroseptal (sensitivity 89%). Right anterior, lateral, and anteroseptal APs were associated with the R/S ratio in aVF ≥1 (sensitivity 98%). Overall sensitivity was 93% and specificity was 99%. Conclusions: This novel algorithm using only the R/S ratio provides a simple and accurate way to identify the AP localization.

Case of Identical Twins Exhibiting Different Type of Brugada Type ECG

We report a rare case of identical twins that exhibited different types of Brugada type ECG. Forty-one year-old identical twins were referred to our hospital for further evaluation of ECG abnormality. Both of the twins exhibited Brugada type ECG. However, the pattern was different. Twin-A exhibited saddle-back type ST elevation in precordial leads and ventricular pre-excitation suggestive of anteroseptal accessory pathway. During Treadmill exercise testing, ventricular pre-excitation was present only when the heart rate was below 120 bpm. The ST level reduced when ventricular pre-excitation abruptly disappeared, and recovered as ventricular pre-excitation recovered. On the other hand, twin-B exhibited spontaneous coved type ST elevation for 4 mm in precordial leads and no ventricular pre-excitation. Echocardiogram showed no structural abnormality for both. Because both are asymptomatic and had no familial history of cardiac sudden death, they had no further evaluation and were put on regular follow-up. In each follow-up visit, the ECG for twin-A and B always show saddle back and coved type ST elevation, respectively. This is the first report of identical twins with Brugada type ECG. Even in identical twins, the degree and type of ST elevation may differ. Further, ventricular pre-excitation may modify ST elevation in Brugada type ECG.

TEE-guided ablation of the anteroseptal accessory pathway from the noncoronary cusp of the aortic valve: A novel application of 3-dimensional images

A 32-year-old man was admitted after sustaining a motor vehicle accident on his all-terrain vehicle due to syncope, resulting in multiple fractured ribs and abrasions. His electrocardiogram (ECG) (Figure 1) demonstrated ventricular pre-excitation consistent with an anteroseptal accessory pathway (AP). Although there was no history of supraventricular tachycardia, there was suspicion that his syncope was secondary to tachyarrhythmia (orthodromic reciprocating tachycardia [ORT] or pre-excited atrial fibrillation).

Examining the causes of ablation failure in the Wolff-Parkinson-White syndrome

the His-bundle at a midseptal or anteroseptal location, increasing the risk of inadvertent complete atrioventricular block. The use of a long sheath may facilitate catheter stability if the accessory pathway is located along the right midseptal or anteroseptal region. In these cases, we favour advancement of the ablation catheter from the right jugular vein, since this site of access is in direct alignment with the location of the accessory pathway. Stable wall contact is accomplished by counterclockwise torque of the catheter. In addition, we found that an anteroseptal pathway may be successfully ablated from the non-coronary cusp. 7 Some operators prefer to use cryothermia. Our laboratory routinely uses RF current when ablating para-Hisian pathways. A His potential is practically always recorded at the earliest site of accessory pathway activation. However, the His bundle is protected by fibrous tissue, whereas the accessory pathway is superficially located, making damage to the His bundle very unlikely with the judicious use of RF energy. An epicardial accessory pathway location may not be amenable to a routine endocardial approach. If a posteroseptal accessory pathway is suspected, coronary sinus angiography will facilitate proper anatomic delineation and catheter ablation. In 21% of patients with a suspected posteroseptal or left posterior accessory pathway, coronary sinus angiography demonstrated a diverticulum originating from the middle cardiac vein, coronary sinus, or both. 8 Ablation is performed by advancing the ablation catheter into the coronary sinus, targeting the neck of the diverticulum. In rare cases, an epicardial accessory pathway may mimic electrocardiographic criteria of a manifest right anteroseptal accessory pathway. Clues to the correct diagnosis during endocardial

210 Incidence and significance of antidromic tachycardia induction in the Wolff-Parkinson-White syndrome

Electrophysiological study (EPS) is recommended in Wolff-Parkinson-White syndrome (WPW). Induction of orthodromic AV reentrant tachycardia (AVRT) is the most frequent. Atrial fibrillation (AF) induction is associated with the prognosis of WPW. Less is known on the induction of antidromic tachycardia (ATD). The purpose of the study was to determine the clinical and electrophysiological data of patients (pts) with a WPW and inducible ATD. EPS was performed in 637 pts with a WPW either for tachycardias (n=335) or syncope (n=88); other pts were asymptomatic (n=213). In control state (CS), the higher rate conducted through accessory pathway (AP) was measured; programmed atrial stimulation with 1 and 2 extrastimuli was performed. The protocol was repeated after isoproterenol infusion. ATD was induced in 45 pts (7%) (group I). The group was compared to remaining pts without inducible ATD (group II). Group I differed from group II by the following data: female sex was less frequent in group I (29.5%) than in group II (47%)(p<0.01); AP was more frequently left lateral sided in group I (54%) than in group II (38%)(p<0.05). AVRT was induced less frequently in group I (34%) than in group II (57%) (p<0.01); maximal rate conducted through AP was higher in group I (214±51 b/min) than in group II (189±61.5) in CS and after isoproterenol (280±56.5 in group I vs 237±61 in group II) (p <0.001). Some data were similar: age was similar in group I (34±20 years) and II (34.5±17); EPS indications were similar: syncope, reentrant tachycardia, spontaneous AF or asymptomatic WPW were the reasons of evaluation respectively in 16%, 43%, 11%, 25% of group I pts and 14%, 46%, 5.5%, 35% of group II pts (NS); left and right posteroseptal AP, anteroseptal AP, right lateral AP and other locations were similar in both groups; AF was induced as frequently in group I (27%) as in group II (23%). ATD was induced more frequently in men than in women and in pts with a left lateral-sided AP, which conducted more rapidly than in pts without inducible ATD. Clinical presentation, age and AF induction were similar in pts with and without inducible ATD.

Successful Targeted Ablation of the Pathway Potential in the Noncoronary Cusp of the Aortic Valve in an Infant with Incessant Orthodromic Atrioventricular Reentrant Tachycardia

A 4-month-old infant presented with incessant SVT and severe failure to thrive. At EP study, orthodromic-reciprocating tachycardia using an anteroseptal accessory pathway was identified. Detailed mapping on the right atrial septum failed to disclose a distinctly early site of atrial activation or a near-field pathway potential. Mapping in the noncoronary cusp of the aortic valve identified a discrete pathway potential that was successfully targeted for ablation. At 12-month follow-up after the procedure, there had been no recurrence of tachycardia. Myocardial fibers above the aortic valve cusps may constitute the atrioventricular bypass connection and can be identified and targeted for successful ablation even in infants.

Is This Atrial Fibrillation?

A 19-year-old girl was referred to our cardiology department for catheter ablation (isolation of the pulmonary veins) of paroxysmal atrial fibrillation (AF). The diagnosis was made upon a 12-lead ECG of the arrhythmia documented in the emergency room. The ECG showed an irregular tachycardia without wide QRS complexes. Careful assessment revealed the irregularity of the rhythm was a sweep artifact due to a mechanic failure of the ECG-machine to advance the article smoothly. During EP study a concealed anteroseptal accessory pathway causing an orthodromic AV reentrant tachycardia was eliminated by radio-frequency ablation. This example emphasizes the need for careful assessment of an ECG tracing, including printed legends and technical data.

Successful cryoablation in the noncoronary aortic cusp for a left anteroseptal accessory pathway

Catheter ablation of anteroseptal accessory pathways may be difficult because of the neighboring conduction tissue that may be damaged with ablation. We report a case of an accessory pathway localized to the anteroseptal region. A pathway potential found in the noncoronary cusp of the aortic valve was successfully targeted for ablation with cryo energy. Observations during tachycardia and pacing maneuvers suggest that the supravalvar aortic musculature may be an integral component of left anteroseptal pathways that can be safely targeted for cryoablation without injury of the atrioventricular conduction system.

Ice mapping during tachycardia in close proximity to the AV node is safe and offers advantages for transcatheter ablation procedures

Background — Ablation during ongoing orthodromic reentry tachycardia (AVRT) and atrioventricular nodal reentry tachycardia (AVNRT) is not recommended using radiofrequency energy when the arrhythmia substrate is located in close proximity to the atrioventricular (AV) node due to a significant risk for inadvertent AV block.The aim of the study is to test the feasibility of ice mapping during tachycardias involving arrhythmia substrate located in close proximity to the AV node.Methods — This was a single-centre, prospective, randomized study. A total of 65 patients was screened and 30 patients with supraventricular arrhythmias were assigned either to a cryo or RF energy group after diagnosis of AVNRT (17 pts) or AVRT (13 pts) with an anteroseptal accessory pathway. RF ablation was performed using standard ablation techniques. In the cryo group, ice mapping was performed during tachycardia with cooling of the catheter tip temperature to a maximum of —40°C. Ablation was performed only if ice mapping terminated the tachycardia without prolongation of the AV conduction.Results — The overall acute success rate was 84%, and was not different in the cryo and RF groups (85% vs. 82.4%, P = 0.43). Both fluoroscopy and the procedure times were comparable.There was a marked reduction in the mean number of applications in the cryo group [2 (1-6) vs. 7 (1-41), P = 0.002]. In one patient ablation was not attempted in the cryo group because of AV prolongation, and in two patients temporary second-degree AV block was observed in the RF group. After 12 months follow-up the long-term success rate was similar between the two groups.Conclusions — (1) Ice mapping is a feasible method to determine the exact location of accessory pathways and of the slow pathway during tachycardia. (2) Ice mapping performed during tachycardia causes less ablation lesions without increasing the procedure and fluoroscopy times.

Catheter Ablation of Paroxysmal Supraventricular Tachycardia

Radiofrequency (RF) catheter ablation became first-line therapy for supraventricular tachycardia in patients with Wolff-Parkinson-White syndrome1–5 and atrioventricular (AV) nodal reentrant tachycardia (AVNRT)6–11 in the early 1990s. High ablation success (>90%) and low complication rates (<5%) were found by numerous investigators.1–11 This article describes these ablation techniques with a focus on approaches to ablation of the forms of accessory AV pathways and AVNRT that are difficult to ablate, as well as the less common variants. Between 1989 and 2005, we performed catheter ablation at the University of Oklahoma Health Sciences Center in 1702 patients with 1728 accessory pathways. Acute ablation success was achieved in 1707 (98.8%) of the 1728 accessory pathways. At the 1-year follow-up, conduction (ventricular preexcitation and/or tachycardia) recurred in 92 (5.4%) of the 1707 accessory pathways that had achieved acute success. The recurrence rate was highest for anteroseptal accessory pathways (17 of 116, 14.7%), intermediate for posteroseptal accessory pathways (48 of 476, 10.1%), and lowest for left and right free-wall accessory pathways (17 of 756, 2.2%; and 10 of 359, 2.8%, respectively). Successful repeat ablation was achieved in 71 of the 92 accessory pathways, for a 1-year success of 1686 (97.6%) of the total 1728 accessory pathways. Of the 1702 patients, 904 (53%) had undergone 1 to 4 prior failed catheter and/or surgical ablation procedures at other institutions. From our experience in these 904 patients, we classify the causes for accessory pathway ablation failure into 3 groups: accessory pathway localization error (60%); unusual and unsuspected accessory pathway location (5%); and technical difficulties, including locations that are difficult to access with the ablation catheter, ablation at sites of low blood flow (limiting RF power), and ablation at sites associated with a high risk of injury to a coronary artery or the AV node (35%). ### Causes of Accessory Pathway Ablation Failure #### Mapping/Localization Error The most …

Ablation of Atrioventricular nodal “slow pathway” for simultaneous treatment of coexisting atrioventricular and nodal reciprocating tachycardias

We report the case of a 49-year-old male patient with recurrent palpitations and two different supraventricular reciprocating tachycardias due to atrioventricular (AV) nodal reentry and orthodromic AV reentry sustained by a left-sided, concealed AV accessory pathway (AP). During the baseline electrophysiological study, dual AV nodal conduction (90 ms jump) and non-decremental, eccentric, ventriculo-atrial conduction due to a left-sided, unidirectional, postero-septal AP were documented. Both typical AV nodal reentrant and orthodromic AV reentrant tachycardias were induced by programmed electrical stimulation. In both cases, shift and sustained conduction over the AV "slow pathway" were required for tachycardia induction and maintenance, respectively. Accordingly, catheter ablation was performed by targeting the AV nodal "slow pathway" first with radiofrequency current applications delivered at the inferior portion of the Koch's triangle. Irritative, slow-rate junctional rhythm was observed during ablation. Afterward, programmed electrical stimulation demonstrated a continuous AV nodal conduction curve, persistent conduction over the AP, and only single orthodromic AV echo beat inducible under baseline condition and pharmacological stress (atropine 0.02 mg/kg i.v. bolus and continuous isoprenaline i.v. administration). Sustained reentrant tachycardias were not inducible any more. For these reasons, the procedure was stopped without any attempt to ablate the AP. After a 4 years follow-up the patient is still asymptomatic without antiarrhythmic drug usage. AV nodal "slow pathway" ablation may abolish both typical AV nodal reentry tachycardia and orthodromic AV reentry tachycardia induction when the latter arrhythmia is dependent from AV nodal "slow pathway" conduction for induction and maintenance. This ablation strategy could be considered, under some instances (e.g. right antero-septal accessory pathways, older patients, etc), in order to reduce the procedure risks due to multiple arrhythmia substrate ablations.

Cryoablation of an anteroseptal accessory pathway

Cryoablation of an anteroseptal accessory pathway

Catheter ablation of anteroseptal accessory pathway in the non-coronary aortic sinus

We report a patient with atrioventricular reentrant tachycardia (AVRT) with bidirectional conduction over an anteroseptal accessory pathway (AP) who underwent successful ablation in the non-coronary aortic sinus (AS). In three previous attempts, the intracardiac recordings showed an anteroseptal AP with antegrade and retrograde conduction that failed to be ablated in spite of radiofrequency (RF) applications from the right and left anteroseptal regions. During the study, the earliest atrial activation during tachycardia was recorded in the non-coronary AS preceding the atrial activation at the His bundle (HB) region by 24 ms, and the anteroseptal AP was successfully blocked by one single ablation in the non-coronary AS. These data strongly suggest that careful mapping of an anteroseptal AP in the non-coronary AS may provide an alternative ablation approach in patients with previously failed ablation.

Case Report of Atrio-Ventricular Reentry Tachycardia Due to Accessory Pathway Having Unidirectional Anterograde Conduction Block and Typical Atrio-Ventricular Nodal Reentry Tachycardia Both Clinically Cured by Ablation of the Only Atrio-Ventricular Nodal “Slow Pathway”

Introduction We report the case of a 49-year old male patient with recurrent palpitations and 2 different supraventricular tachycardias due to atrio-ventricular (AV) nodal reentry and orthodromic AV reentry sustained by a left-sided, unidirectional, AV accessory pathway (AP) evidenced during electrophysiological study. Method and Results During the baseline electrophysiological study, dual AV nodal conduction (90 ms A2H2 sudden jump at 320 ms A1A2 coupling interval), and non-decremental, eccentric, ventriculo-atrial conduction due to a left-sided, unidirectional, postero-septal AP were documented. Both typical AV nodal reentrant and orthodromic AV reentrant tachycardias were induced by programmed electrical stimulation several times. Intervals measured during each tachycardia are reported in the Table. The diagnosis of tachycardia mechanism was performed according to standard criteria. In both cases, shift and sustained conduction over the AV “slow pathway” were required for tachycardia inductions and maintenances, respectively. Accordingly, catheter ablation was performed by targeting the AV nodal “slow pathway” first with radiofrequency current applications delivered at the inferior portion of the Koch's triangle. Irritative, slow-rate junctional rhythm was observed during ablation. Afterward, programmed electrical stimulation demonstrated continuous AV nodal conduction curve, persistent conduction over the AP, and only single orthodromic AV echo beats inducible under baseline condition and pharmacological stress (atropine 0.02 mg/kg i.v. bolus and continuous isoprenaline i.v. administration). Sustained reentrant tachycardias were not inducible any more. For these reasons, the procedure was stopped without any attempt to ablate the AP. After a 18 month follow-up the patient is still asymptomatic without antiarrhythmic drug usage. Conclusion AV nodal “slow pathway” ablation may abolish both typical AV nodal reentry tachycardia and orthodromic AV reentry tachycardia induction when the latter arrhythmia is dependent from AV nodal “slow pathway” conduction for induction and maintenance. This ablation strategy resulted in a mid-term clinical success in the reported case, and it could be considered, under some instances (i.e. right antero-septal accessory pathways, older patients, etc), in order to reduce the procedure risks due to multiple arrhytmia substrates. ![Graphic][1] [1]: /embed/graphic-1.gif

Electrocardiographic Characteristics of Fasciculoventricular Pathways

Fasciculoventricular (FV) pathways are rare variants of preexcitation, and their ECGs may be misinterpreted as Wolff-Parkinson-White syndrome with anteroseptal accessory pathways (WPW-AS). We analyzed the electrocardiographic characteristics of the patients with FV pathways to find out the different findings from WPW-AS. Five patients with FV pathways and four patients with WPW-AS who underwent electrophysiologic studies were evaluated. Intervals and amplitudes of each wave and QRS morphologies were analyzed in standard 12-lead ECGs of these patients by two independent cardiologists without the information of the electrophysiologic findings. PR intervals were longer in FV pathways (122 +/- 11.0 vs 83 +/- 21 ms, FV pathways vs WPW-AS, P = 0.017). In lead V1, narrower width of R waves (25 +/- 6 vs 45 +/- 13 ms, P = 0.037) and smaller amplitude of S waves (12.8 +/- 8.3 vs 26.6 +/- 7.4 mm, P = 0.037) were observed in FV pathways. The polarity of delta waves in V1 was flat or negative in contrast with the cases of WPW-AS in which the polarity was positive. Three of five patients had notching in the descending limb of S waves in V1, which was not observed in WPW-AS. FV pathways have different ECG characteristics from WPW-AS in PR interval and morphology of QRS complexes in lead V1 of the standard 12-lead ECG.