EP ROUNDS
Adenosine Administration Following Pulmonary Vein Isolation: What Is Occurring? SHADI IDRIS, M.D., SUJANA GUNDLAPALLI, M.D., and DIPAK P. SHAH, M.D. From the Department of Cardiology, Providence Hospital, Southfield, Michigan
A 22-year-old with paroxysmal atrial fibrillation (PAF) and palpitations for 2 years has been having a worsening burden of symptoms. Although he has no medical history, his father had AF in his early 40s and had an ablation. The patient was hospitalized twice in the last 3 months for PAF at an outside hospital. The patient refused medication treatment with antiarrhythmic
drugs and elected for ablation. After completing antral pulmonary vein isolation (PVI), intravenous adenosine was used to assess for PV latent recovery.1 The finding below was seen when all four PVs were assessed. What is the significance of the atrial signal highlighted (Fig. 1)? The differential includes blocked premature atrial contractions from a non-PV trigger versus
Figure 1. Sinus rhythm with transient atrioventricular (AV) block following adenosine administration. Shown are electrocardiogram leads I, aVF, and V1, as well as bipolar electrocardiogram recordings from a Lasso catheter (LSO) positioned in the left superior pulmonary vein, the coronary sinus (CS), and the ablation catheter (ABL) positioned on the left atrial anterior wall. Complete heart block is evident for the first two sinus beats while the remaining beats display AV nodal recovery with an atrial signal following the QRS complex (arrow).
No conflicts, disclosures, or funding relevant for all authors relevant for this paper. Address for reprints: Dipak P. Shah, Department of Cardiology, Providence Hospital, 22250 Providence Dr.,Suite 705, Southfield, MI 48075. Fax: 248-552-9510; e-mail: [email protected] Received July 13, 2014; accepted July 25, 2014. doi: 10.1111/pace.12516
©2014 Wiley Periodicals, Inc. 520
April 2015
PACE, Vol. 38
ADENOSINE ADMINISTRATION FOLLOWING PULMONARY VEIN ISOLATION
an echo beat. The fixed coupling interval between the ventricular and atrial signal on multiple beats occurring only in the presence of adenosine supports a concealed accessory pathway. Adenosine washout likely created enough AV nodal delay to allow conducted echo beats through the concealed accessory pathway. Isoproterenol was then administered at 2 mcg/min and a tachycardia with a cycle length of 220 ms was easily induced. Pacing maneuvers confirmed
orthodromic reciprocating tachycardia (ORT)2 and mapping revealed the earliest site of activation at the coronary sinus ostium. Ablation at this location terminated the tachycardia and rendered it noninducible. The patient’s AF was likely triggered by his ORT. In the era of AF ablation, this case highlights the importance of an initial electrophysiology study, especially in younger individuals with minimal AF risk factors, prior to PVI.
References 1. Datino T, Macle L, Chartier D, Comtois P, Khairy P, Guerra PG, Fernandez-Aviles F, et al. Differential effectiveness of pharmacological strategies to reveal dormant pulmonary vein conduction: A clinical-experimental correlation. Heart Rhythm 2011; 8: 1426–1433.
PACE, Vol. 38
2. Gonz´alez-Torrecilla E, Arenal A, Atienza F, Osca J, Garc´ıaFern´andez J, Puchol A, S´anchez A, et al. First postpacing interval after tachycardia entrainment with correction for atrioventricular node delay: A simple maneuver for differential diagnosis of atrioventricular nodal reentrant tachycardias versus orthodromic reciprocating tachycardias. Heart Rhythm 2006; 6:674–679.
April 2015
521
This document is a scanned copy of a printed document. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material.
Adenosine Administration Following Pulmonary Vein Isolation: What Is Occurring? SHADI IDRIS, M.D., SUJANA GUNDLAPALLI, M.D., and DIPAK P. SHAH, M.D. From the Department of Cardiology, Providence Hospital, Southfield, Michigan
A 22-year-old with paroxysmal atrial fibrillation (PAF) and palpitations for 2 years has been having a worsening burden of symptoms. Although he has no medical history, his father had AF in his early 40s and had an ablation. The patient was hospitalized twice in the last 3 months for PAF at an outside hospital. The patient refused medication treatment with antiarrhythmic
drugs and elected for ablation. After completing antral pulmonary vein isolation (PVI), intravenous adenosine was used to assess for PV latent recovery.1 The finding below was seen when all four PVs were assessed. What is the significance of the atrial signal highlighted (Fig. 1)? The differential includes blocked premature atrial contractions from a non-PV trigger versus
Figure 1. Sinus rhythm with transient atrioventricular (AV) block following adenosine administration. Shown are electrocardiogram leads I, aVF, and V1, as well as bipolar electrocardiogram recordings from a Lasso catheter (LSO) positioned in the left superior pulmonary vein, the coronary sinus (CS), and the ablation catheter (ABL) positioned on the left atrial anterior wall. Complete heart block is evident for the first two sinus beats while the remaining beats display AV nodal recovery with an atrial signal following the QRS complex (arrow).
No conflicts, disclosures, or funding relevant for all authors relevant for this paper. Address for reprints: Dipak P. Shah, Department of Cardiology, Providence Hospital, 22250 Providence Dr.,Suite 705, Southfield, MI 48075. Fax: 248-552-9510; e-mail: [email protected] Received July 13, 2014; accepted July 25, 2014. doi: 10.1111/pace.12516
©2014 Wiley Periodicals, Inc. 520
April 2015
PACE, Vol. 38
ADENOSINE ADMINISTRATION FOLLOWING PULMONARY VEIN ISOLATION
an echo beat. The fixed coupling interval between the ventricular and atrial signal on multiple beats occurring only in the presence of adenosine supports a concealed accessory pathway. Adenosine washout likely created enough AV nodal delay to allow conducted echo beats through the concealed accessory pathway. Isoproterenol was then administered at 2 mcg/min and a tachycardia with a cycle length of 220 ms was easily induced. Pacing maneuvers confirmed
orthodromic reciprocating tachycardia (ORT)2 and mapping revealed the earliest site of activation at the coronary sinus ostium. Ablation at this location terminated the tachycardia and rendered it noninducible. The patient’s AF was likely triggered by his ORT. In the era of AF ablation, this case highlights the importance of an initial electrophysiology study, especially in younger individuals with minimal AF risk factors, prior to PVI.
References 1. Datino T, Macle L, Chartier D, Comtois P, Khairy P, Guerra PG, Fernandez-Aviles F, et al. Differential effectiveness of pharmacological strategies to reveal dormant pulmonary vein conduction: A clinical-experimental correlation. Heart Rhythm 2011; 8: 1426–1433.
PACE, Vol. 38
2. Gonz´alez-Torrecilla E, Arenal A, Atienza F, Osca J, Garc´ıaFern´andez J, Puchol A, S´anchez A, et al. First postpacing interval after tachycardia entrainment with correction for atrioventricular node delay: A simple maneuver for differential diagnosis of atrioventricular nodal reentrant tachycardias versus orthodromic reciprocating tachycardias. Heart Rhythm 2006; 6:674–679.
April 2015
521
This document is a scanned copy of a printed document. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material.
