Concealed Left-sided Accessory Pathway Research Articles

Atrial activation sequence changes during ventricular overdrive pacing: What is the mechanism?

We describe atrial activation sequence changes during ventricular overdrive pacing in a patient with a concealed left-sided accessory pathway and discuss its potential mechanism.

Supraventricular tachycardia with alternating eccentric atrial activation: What is the mechanism?

We report an orthodromic atrioventricular reciprocating tachycardia using two alternating concealed left-sided accessory pathways. This case provides insights into the differential diagnosis of supraventricular tachycardia with alternating ventriculoatrial intervals. This article is protected by copyright. All rights reserved.

The "hidden" concealed left-sided accessory pathway: An uncommon cause of SVT in young people.

Concealed left-sided accessory pathways (CLAP) are a cause of supraventricular tachycardia (SVT) in the young. Most are mapped with right ventricular (RV) apical/outflow pacing. Rarely, alternative means of mapping are required. We review our experience from three pediatric electrophysiology (EP) centers with a rare form of "hidden" CLAP. All patients<21 years undergoing EP study from 2008 to 2014 with a "hidden" CLAP (defined as an accessory pathway [AP] for which RV pacing at cycle lengths [CL] stable for mapping did not demonstrate eccentric retrograde conduction) were included. preexcitation. Demographic, procedural, and follow-up data were collected. A total of 23 patients met the criteria (median age, 14.3 years [range 7-21], weight, 51kg [31-99]). 21 (96%) had SVT and one AFIB (4%). APs were adenosine sensitive in 7/20 patients (35%) and VA conduction was decremental in six (26%). CLAP conduction was demonstrable with orthodromic reentrant tachycardia in all patients, with RV extrastimulus testing in seven (30%) and with rapid RV pacing (<CL 300) in three (13%). Left ventricular (LV) pacing demonstrated CLAP conduction in 17/17 (100%) patients in whom it was used. All 23 CLAPs were successfully ablated (100%) via transseptal approach with radiofrequency energy. Specific ablation techniques included: 16 (70%) during LV paced rhythm, four (17%) during orthodromic reciprocating tachycardia (ORT; 3/4 ventricular entrained), and three (13%) with brief rapid RV pacing. There were no complications. At 18 months (range 3-96), there was one recurrence (4%). Some CLAPs are only demonstrable with LV pacing, entrained ORT, or rapid RV pacing. LV pacing facilitated preferential AP conduction, allowing for mapping while maintaining stable hemodynamics.

Evidence for an incomplete mitral isthmus block after failed ablation of a left postero-inferior concealed accessory pathway

We report the case of a young woman in whom previous ablation of a concealed left-sided accessory pathway (AP) created an iatrogenic mitral block. The mitral block was responsible for a split retrograde atrial activation pattern during orthodromic atrioventricular re-entrant tachycardia (AVRT). The differential diagnoses are discussed. The AP was ablated at the site with the shortest interval between the ventricular signal and the earliest component of the retrograde atrial activation. Meticulous mapping is paramount during AVRT with an unusual retrograde atrial activation pattern.

A Unipolar Coronary Sinus Mapping Study of Patients with Left-Sided Atrioventricular Accessory Pathways

So-called unipolar 'PQS pattern' is widely accepted as a hallmark of successful catheter ablation of the left-sided atrioventricular accessory pathway. However, the unipolar nature of the electrogram and the site-dependent appearance of this characteristic pattern are poorly understood. Therefore, unipolar coronary sinus (CS) mapping was performed using a multipolar fine electrode in patients with Wolff-Parkinson-White (WPW) syndrome associated with an antegrade left-sided accessory pathway (case group) and those with a concealed left-sided accessory pathway or atrioventricular nodal reentrant tachycardia (control group) under sinus rhythm and fixed high right atrial, CS ostial, and distal pacing. In both groups, the unipolar CS atrial electrogram showed intrinsic negative deflection (initial positive followed by negative parts) with considerable variation depending on the recording site. This unipolar configuration of the atrial electrogram was not influenced by different activation sequences during pacing at various sites. The case group exhibited a unipolar 'PQS pattern' at successful ablation sites for the left lateral to anterolateral accessory pathway. However, this was not true for the left posteroseptal accessory pathway, possibly because the negative part of the atrial electrogram distorted the 'PQS pattern' as an intervening dip. In conclusion, the site-dependent variations of the unipolar CS atrial electrogram underlie the limited usefulness of the 'PQS pattern' in left posteroseptal accessory pathway localization.

Localization of the ventricular insertion site of concealed left-sided accessory pathways using ventricular pace mapping.

The aim of the present study was to localize the ventricular insertion site of concealed accessory pathway (APs) by using the ventricular pace mapping and examined if the analysis of the timing of retrograde atrial electrogram recorded at the ventricular side of the mitral annulus is useful in identifying the ventricular insertion site of the AP. In 39 patients with concealed left-sided APs, ventricular pacing was delivered along the mitral annulus at a cycle length of 500 ms while measuring the conduction interval from the pacing stimulus to the earliest retrograde atrial electrogram recorded in the coronary sinus (St-A). The ventricular insertion site of the AP was localized by identifying the shortest St-A. Also the interval between the onsets of QRS and atrial electrograms (QRS-A) and presence of continuous electrical activity (CEA) between the ventricular and atrial electrograms were evaluated at each mapping site during atrioventricular reciprocating tachycardia. Initial radiofrequency energy application to the site with the shortest St-A (46 +/- 15 ms) eliminated the AP conduction in all patients, suggesting the accurate localization of the ventricular insertion site by ventricular pace mapping. The QRS-A and the percentage of the presence of CEA at the shortest St-A site were 79 +/- 19 ms and 64%, respectively. However, the earliest retrograde atrial activation site did not coincide with the shortest St-A site in 19 of 39 patients, suggesting an oblique course of AP. Thus, in these 19 patients, there was a significant difference in St-A (47 +/- 16 vs 59 +/- 15 ms, P < 0.0001), QRS-A (83 +/- 13 vs 72 +/- 12 ms, P < 0.0001) and the presence of CEA (32 vs 74%, P < 0.01) between the shortest St-A site and the earliest retrograde atrial activation site, respectively. These indicate that the earliest retrograde atrial activation is not necessarily indicative of the ventricular insertion site of AP. However, ventricular pace mapping was considered to be useful for identifying and ablating the ventricular insertion site of AP, irrespective of the course of AP.

Body-surface distribution of changes in activation-recovery intervals before and after catheter ablation in patients with Wolff-Parkinson-White syndrome: clinical evidence for ventricular 'electrical remodeling' with prolongation of action-potential duration over a preexcited area.

T-wave abnormalities after catheter ablation in patients with manifest Wolff-Parkinson-White (WPW) syndrome have been attributed to a continuation of repolarization abnormalities induced by preexcitation (cardiac memory). To clarify changes in repolarization properties, we analyzed the activation-recovery interval (ARI) obtained from body-surface maps and the relationship between the activation time (AT) and ARI in 30 patients with WPW syndrome (group A, 18 patients with manifest left-sided accessory pathway; group B, 7 patients with manifest right-sided accessory pathway; and group C, 5 patients with concealed left-sided accessory pathway) before, 1 day after, and 1 week after ablation. The ARI significantly decreased 1 week after ablation compared with before and 1 day after ablation over the preexcited area in groups A and B. Correlation coefficients between the AT and ARI showed a significantly (P<.01) stronger inverse relationship before (r=-.58) and 1 week after (r=-.64) ablation than 1 day after ablation (r=-.46) in groups A and B. In group C, the ARI and correlation coefficients between the AT and ARI showed no significant changes. These findings suggest a prolongation of the action-potential duration over the preexcited area before and just after ablation as ventricular "electrical remodeling," a decrease in the inverse relationship between the AT and action-potential duration 1 day after ablation, and a gradual recovery of the action-potential duration over the preexcited area and inverse relationship 1 week after ablation.

Ablación mediante radiofrecuencia de vías accesorias ocultas izquierdas sin cateterismo del seno coronario

Radiofrequency catheter ablation of concealed left-sided accessory pathways conventionally implies the introduction of several catheters for the assessment of electrophysiological properties as well as for the localization of the accessory pathways. Feasibility of radiofrequency ablation using a simplified two-catheter technique without coronary sinus catheterization was prospectively studied in 95 consecutive patients with a single concealed left free-wall accessory pathway. A 6F quadripolar catheter was introduced into the right atrium/right ventricle and tachycardia was induced by electrical stimulation. The presence of a concealed left-sided accessory pathway was suggested electrocardiographically (negative P wave in I and/or aVL during orthodromic tachycardia) or by earlier atrial activation in the pulmonary artery compared to the right atrium. Mapping of the mitral annulus and ablation were performed during orthodromic tachycardia or ventricular pacing using a 7F steerable catheter. Radiofrequency energy was applied at sites with the shortest VA interval. The procedure was considered effective if tachycardia could not be induced and if VA dissociation or exclusive nodal VA conduction were observed. The procedure was initially successful in 93 out of 95 patients (98%). Mean number of applications were 3.2 +/- 2. Mean fluoroscopy time and total procedure duration were 14 +/- 9 and 108 +/- 33 minutes respectively. At a mean follow-up of 21 +/- 13 months, 2 patients required a second session because of tachycardia recurrence. Radiofrequency catheter ablation of concealed left-sided accessory pathways can be safely, effectively and rapidly performed using a two-catheter technique without coronary sinus catheterization.

“Pseudodisappearance” of atrial electrogram during orthodromic tachycardia: New criteria for successful ablation of concealed left-sided accessory pathways

Objectives. This study sought to analyze two new criteria along with other known predictors of success of radiofrequency ablation.Background. Although the overall success rate of radiofrequency ablation of accessory pathways is high, the individual predictive value of each of the established criteria is low.Methods. We prospectively studied the local electrograms obtained before the application of radiofrequency energy in 33 patients with a left-sided concealed accessory pathway successfully ablated. Two new criteria (“pseudodisappearance” during tachycardia of a bipolar atrial electrogram visible during sinus rhythm and the presence of an “atrial notch” in the ascending limb of the unipolar ventricular electrogram during tachycardia) were studied along with other known predictors. Electrograms recorded at a total of 157 sites were analyzed (33 successful applications, 124 failures).Results. Electrogram characteristics that were predictive of success during ablation on the basis of univariate analyses were a pseudodisappearance criterion (p < 0.001), the presence of a Kent potential (p < 0.005) and the presence of an “atrial notch” (p < 0.005). After adjustment for between-patient differences, logistic regression analysis showed that only the “pseudodisappearance” criterion (odds ratio [OR] 7.2, 95% confidence interval [CI] 1.2 to 42.5, p < 0.03) and the presence of a Kent potential (OR 2.4, 95% CI 1.01 to 5.79, p < 0.05) had independent predictive value.Conclusions. The pseudodisappearance during tachycardia or ventricular pacing of a bipolar atrial electrogram present during sinus rhythm is associated with a good outcome during radiofrequency ablation of concealed accessory pathways. These observations may help to ablate accessory pathways and to avoid missing appropriate sites for ablation when the atrial activation is not clearly visible at the local electrogram.

Body surface distribution of significant changes in QRST time-integral values after radiofrequency catheter ablation in patients with Wolff-Parkinson-White syndrome

We analyzed 87-lead body surface QRST time-integral values (QRST values) in 29 patients with Wolff-Parkinson-White syndrome (group A, 17 patients with manifest left-sided accessory pathway; group B, 6 patients with manifest right-sided accessory pathway; and group C, 6 patients with concealed left-sided accessory pathway), before, 1 day after, and 1 week after radiofrequency catheter ablation (RCA). The number of leads with abnormal QRST values was significantly lower 1 week after RCA compared with those before RCA and 1 day after RCA in groups A and B (p < 0.05); there was no significant difference in QRST values before and 1 day after RCA in groups A and B. The QRST values over areas with preexisting repolarization abnormalities were significantly altered 1 week after RCA compared with before and 1 day after RCA in groups A and B (p < 0.01). However, there was no significant difference in the QRST values over areas without preexisting abnormalities before RCA. In group C, there were no significant differences in the QRST values or the number of leads with abnormal QRST values before, 1 day and 1 week after RCA. In conclusion, RCA did not significantly influence repolarization properties over areas without preexisting abnormalities, but gradually reduced preexisting repolarization abnormalities, which were closely related to the location of the accessory pathway in patients with manifest Wolff-Parkinson-White syndrome. Our results suggest that body surface QRST values are useful for assessment of repolarization abnormalities during the periablation period.

Surgical Treatment of Atrioventricular Atresia Combined With Wolff-Parkinson-White Syndrome

Tachyarrhythmia has been thought to be an absolute contraindication for the Fontan operation. Three patients, 22, 9, and 11 years of age, diagnosed as having atrioventricular atresia combined with the Wolff-Parkinson-White syndrome underwent surgical treatment. Each had drug-resistant atrioventricular tachycardia that required direct cardioversion. Two patients with tricuspid atresia had an intermittent right-sided accessory pathway (ACP), and one with mitral atresia had a concealed left-sided ACP. The ACP was divided using an epicardial approach in two patients and an endocardial approach in one. Simultaneously, the Fontan operation was performed with atrioventricular connection (modified Fontan operation) in one patient, and a total cavopulmonary connection performed in another patient. In the remaining patient, ACP division was performed 3 years after the Fontan operation. There was no early death or other fatal complication, and the hemodynamic results were excellent. During the mean follow-up period of 68 months (range, 5 to 127 months), there has been no late death or recurrence of tachyarrhythmia. Tachyarrhythmias caused by ACPs are not contraindications for the Fontan operation. Concomitant surgery is advocated, as excellent short- and long-term results may be expected in these patients.

Spontaneous Incessant AV Reentrant Tachycardia Related to Left Bundle Branch Block and Concealed Left‐Sided Accessory AV Pathway

Three patients in whom permanent AV reentrant tachycardia became the clinical manifestation of Wolff-Parkinson-White syndrome are described. The substrate for the arrhythmia was created by coexistence of a concealed left-sided accessory pathway and an ipsilateral bundle branch block. Pharmacologic therapy in all three patients failed to control the tachycardia, which in two cases led to severe left ventricular failure. After successful radiofrequency ablation of the accessory pathway (in two) or AV junction (in one), left ventricular function gradually returned to normal.