A n t i d ro m i c Atrioventricular Reciprocating Tachycard ia U s i n g a C o n c e a l e d R e t ro g r a d e Conducting Left Lateral Accessory Pathway Jaime E. Gonzalez, MD, Matthew M. Zipse, MD, Duy T. Nguyen, MD, William H. Sauer, MD* KEYWORDS Catheter ablation Accessory pathways Wolf Parkinson White
KEY POINTS
CLINICAL PRESENTATION A 35-year-old man with a history of palpitations and preexcitation underwent prior electrophysiologic study and ablation. He had a reported ablation of a pathway in the coronary sinus as well as a left-sided para-Hisian pathway that was not successfully ablated. Since then the patient has had recurrent documented supraventricular tachycardia with symptoms of dizziness and palpitations that have been refractory to betablockers and flecainide. He was referred for a repeat electrophysiologic study and possible ablation.
ELECTROPHYSIOLOGY STUDY Venous access was obtained in the left and right femoral veins; under fluoroscopic guidance,
catheters were placed in the right atrium, His bundle region, right ventricle, and coronary sinus. Baseline electrocardiogram showed evident preexcitation with a left bundle morphology and left indeterminate axis (Fig. 1). Baseline intracardiac electrograms showed a negative His-Ventricular (HV) interval (Figs. 2 and 3). The Halo catheter (Biosense-Webster, Diamond Bar, CA) was placed with Halo 1-2 close to the coronary sinus, Halo 78 in the right lateral free wall, and Halo 11-12 in the high right atrium. Ventricular pacing demonstrated earliest activation in the lateral coronary sinus and right free wall (Fig. 4). Programmed ventricular and atrial extrastimulation easily induced tachycardia with manifest preexcitation and with earliest atrial activation in the distal coronary sinus. Ventricular overdrive pacing of the tachycardia demonstrated a V-A-V-A response
Cardiac Electrophysiology, Cardiology Division, University of Colorado, Denver, Anschutz Medical Campus, 12401 East 17th Avenue, B-132, Aurora, CO 80045, USA * Corresponding author. E-mail address: [email protected] Card Electrophysiol Clin 8 (2016) 37–43 http://dx.doi.org/10.1016/j.ccep.2015.10.001 1877-9182/16/$ – see front matter Ó 2016 Elsevier Inc. All rights reserved.
cardiacEP.theclinics.com
Atrioventricular reciprocating tachycardia is a common cause of undifferentiated supraventricular tachycardia. In patients with manifest or concealed accessory pathways, it is imperative to assess for the presence of other accessory pathways. In rare cases, multiple accessory pathways can act as the anterograde and retrograde limbs of the tachycardia.
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Gonzalez et al
Fig. 1. Resting 12-lead electrocardiogram showing manifest preexcitation.
consistent with atrioventricular tachycardia (AVRT) (Fig. 5).
reciprocating
QUESTION What is the diagnosis and mechanism of the arrhythmia?
DISCUSSION The electrograms illustrate an AVRT using a right free wall pathway as the anterograde limb and a left lateral free wall pathway as the retrograde limb. The evidence for this lies in the presence of manifest preexcitation without a His electrogram in tachycardia as well as retrograde activation via a left lateral pathway. The V-A-V response to overdrive pacing excludes an atrial tachycardia
originating from the left atrium.11 A paced atrial premature beat during tachycardia demonstrates anterograde conduction through the AV node and His bundle. Anterograde AV nodal conduction during tachycardia is likely not present because of the retrograde invasion of the His bundle during tachycardia with a long refractory period due to conduction slowing in the His-Purkinje system.
CLINICAL COURSE Electroanatomic mapping of the right free wall pathway was performed by assessing for earliest retrograde atrial and anterograde ventricular signals. Earliest atrial activation was performed with ventricular pacing. Earliest ventricular activation was performed with atrial pacing and during
Unusual Antidromic AVRT Fig. 2. Baseline intracardiac with manifest preexcitation and a negative HV interval followed by atrial pacing in the coronary sinus with loss of preexcitation and an HV interval of 69 milliseconds.
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Gonzalez et al
Fig. 3. Atrial pacing during tachycardia demonstrating a clear His signal and loss of preexcitation.
Unusual Antidromic AVRT Fig. 4. Ventricular pacing with earliest activation in the lateral coronary sinus and Halo 7-8 in the right lateral free wall demonstrating the presence of 2 accessory pathways with retrograde conduction.
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Gonzalez et al Fig. 5. Ventricular overdrive pacing with a V-A-V-A response to entrainment. There is antegrade conduction down the right-sided accessory pathway as evidenced by the left bundle morphology without a His signal. There is also earliest retrograde activation at the lateral coronary sinus observed during tachycardia.
Unusual Antidromic AVRT tachycardia. There were no fascicular potentials noted on the ventricular insertion site excluding an atrio-fascicular pathway. The area of earliest atrial activation was noted to be quite broad, consistent with multiple insertion sites. A medium curl Agilis sheath (St. Jude Medical, St Paul, MN) was used for stability in the right lateral free wall and after several radio frequency (RF) lesions, the right free wall pathway was successfully ablated. After transseptal access, the left lateral free wall pathway was then mapped during ventricular pacing and the earliest atrial insertion was found at 5 o’clock on the mitral annulus. Several RF lesions were delivered at the site of earliest activation with elimination of this pathway. After ablation of these two pathways, no other pathways or tachycardias were noted or induced. Manifest preexcitation was not present. The atrial-His interval was 130 milliseconds; the HV was prolonged at 69 milliseconds, likely because of injury from a previous ablation of a para-Hisian accessory pathway. VA conduction was midline, concentric, and decremental. Para-Hisian pacing was consistent with an AV nodal response. Since ablation, the patient has had no recurrence of symptoms.
SUMMARY AVRT is a common cause of undifferentiated supraventricular tachycardia. In patients with manifest or concealed accessory pathways, it is imperative to assess for the presence of other accessory pathways. Multiple accessory pathways are present in 4% to 10% of patients and are more common in patients with structural heart disease.2,3 In rare cases, multiple accessory pathways can act as the anterograde and retrograde limbs of the tachycardia.
REFERENCES 1. Knight BP, Ebinger M, Oral H, et al. Diagnostic value of tachycardia features and pacing maneuvers during paroxysmal supraventricular tachycardia. J Am Coll Cardiol 2000;36:574–82. 2. Iturralde P, Guevara-Valdivia M, Rodrı´guez-Cha´vez L, et al. Radiofrequency ablation of multiple accessory pathways. Europace 2002;4:273–80. 3. Zachariah JP, Walsh EP, Triedman JK, et al. Multiple accessory pathways in the young: the impact of structural heart disease. Am Heart J 2013;165:87–92.
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KEY POINTS
CLINICAL PRESENTATION A 35-year-old man with a history of palpitations and preexcitation underwent prior electrophysiologic study and ablation. He had a reported ablation of a pathway in the coronary sinus as well as a left-sided para-Hisian pathway that was not successfully ablated. Since then the patient has had recurrent documented supraventricular tachycardia with symptoms of dizziness and palpitations that have been refractory to betablockers and flecainide. He was referred for a repeat electrophysiologic study and possible ablation.
ELECTROPHYSIOLOGY STUDY Venous access was obtained in the left and right femoral veins; under fluoroscopic guidance,
catheters were placed in the right atrium, His bundle region, right ventricle, and coronary sinus. Baseline electrocardiogram showed evident preexcitation with a left bundle morphology and left indeterminate axis (Fig. 1). Baseline intracardiac electrograms showed a negative His-Ventricular (HV) interval (Figs. 2 and 3). The Halo catheter (Biosense-Webster, Diamond Bar, CA) was placed with Halo 1-2 close to the coronary sinus, Halo 78 in the right lateral free wall, and Halo 11-12 in the high right atrium. Ventricular pacing demonstrated earliest activation in the lateral coronary sinus and right free wall (Fig. 4). Programmed ventricular and atrial extrastimulation easily induced tachycardia with manifest preexcitation and with earliest atrial activation in the distal coronary sinus. Ventricular overdrive pacing of the tachycardia demonstrated a V-A-V-A response
Cardiac Electrophysiology, Cardiology Division, University of Colorado, Denver, Anschutz Medical Campus, 12401 East 17th Avenue, B-132, Aurora, CO 80045, USA * Corresponding author. E-mail address: [email protected] Card Electrophysiol Clin 8 (2016) 37–43 http://dx.doi.org/10.1016/j.ccep.2015.10.001 1877-9182/16/$ – see front matter Ó 2016 Elsevier Inc. All rights reserved.
cardiacEP.theclinics.com
Atrioventricular reciprocating tachycardia is a common cause of undifferentiated supraventricular tachycardia. In patients with manifest or concealed accessory pathways, it is imperative to assess for the presence of other accessory pathways. In rare cases, multiple accessory pathways can act as the anterograde and retrograde limbs of the tachycardia.
38
Gonzalez et al
Fig. 1. Resting 12-lead electrocardiogram showing manifest preexcitation.
consistent with atrioventricular tachycardia (AVRT) (Fig. 5).
reciprocating
QUESTION What is the diagnosis and mechanism of the arrhythmia?
DISCUSSION The electrograms illustrate an AVRT using a right free wall pathway as the anterograde limb and a left lateral free wall pathway as the retrograde limb. The evidence for this lies in the presence of manifest preexcitation without a His electrogram in tachycardia as well as retrograde activation via a left lateral pathway. The V-A-V response to overdrive pacing excludes an atrial tachycardia
originating from the left atrium.11 A paced atrial premature beat during tachycardia demonstrates anterograde conduction through the AV node and His bundle. Anterograde AV nodal conduction during tachycardia is likely not present because of the retrograde invasion of the His bundle during tachycardia with a long refractory period due to conduction slowing in the His-Purkinje system.
CLINICAL COURSE Electroanatomic mapping of the right free wall pathway was performed by assessing for earliest retrograde atrial and anterograde ventricular signals. Earliest atrial activation was performed with ventricular pacing. Earliest ventricular activation was performed with atrial pacing and during
Unusual Antidromic AVRT Fig. 2. Baseline intracardiac with manifest preexcitation and a negative HV interval followed by atrial pacing in the coronary sinus with loss of preexcitation and an HV interval of 69 milliseconds.
39
40
Gonzalez et al
Fig. 3. Atrial pacing during tachycardia demonstrating a clear His signal and loss of preexcitation.
Unusual Antidromic AVRT Fig. 4. Ventricular pacing with earliest activation in the lateral coronary sinus and Halo 7-8 in the right lateral free wall demonstrating the presence of 2 accessory pathways with retrograde conduction.
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Gonzalez et al Fig. 5. Ventricular overdrive pacing with a V-A-V-A response to entrainment. There is antegrade conduction down the right-sided accessory pathway as evidenced by the left bundle morphology without a His signal. There is also earliest retrograde activation at the lateral coronary sinus observed during tachycardia.
Unusual Antidromic AVRT tachycardia. There were no fascicular potentials noted on the ventricular insertion site excluding an atrio-fascicular pathway. The area of earliest atrial activation was noted to be quite broad, consistent with multiple insertion sites. A medium curl Agilis sheath (St. Jude Medical, St Paul, MN) was used for stability in the right lateral free wall and after several radio frequency (RF) lesions, the right free wall pathway was successfully ablated. After transseptal access, the left lateral free wall pathway was then mapped during ventricular pacing and the earliest atrial insertion was found at 5 o’clock on the mitral annulus. Several RF lesions were delivered at the site of earliest activation with elimination of this pathway. After ablation of these two pathways, no other pathways or tachycardias were noted or induced. Manifest preexcitation was not present. The atrial-His interval was 130 milliseconds; the HV was prolonged at 69 milliseconds, likely because of injury from a previous ablation of a para-Hisian accessory pathway. VA conduction was midline, concentric, and decremental. Para-Hisian pacing was consistent with an AV nodal response. Since ablation, the patient has had no recurrence of symptoms.
SUMMARY AVRT is a common cause of undifferentiated supraventricular tachycardia. In patients with manifest or concealed accessory pathways, it is imperative to assess for the presence of other accessory pathways. Multiple accessory pathways are present in 4% to 10% of patients and are more common in patients with structural heart disease.2,3 In rare cases, multiple accessory pathways can act as the anterograde and retrograde limbs of the tachycardia.
REFERENCES 1. Knight BP, Ebinger M, Oral H, et al. Diagnostic value of tachycardia features and pacing maneuvers during paroxysmal supraventricular tachycardia. J Am Coll Cardiol 2000;36:574–82. 2. Iturralde P, Guevara-Valdivia M, Rodrı´guez-Cha´vez L, et al. Radiofrequency ablation of multiple accessory pathways. Europace 2002;4:273–80. 3. Zachariah JP, Walsh EP, Triedman JK, et al. Multiple accessory pathways in the young: the impact of structural heart disease. Am Heart J 2013;165:87–92.
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