547 Supernormal conduction of an accessory pathway: the case of a young sportsman

Abstract Aims Ventricular pre-excitation is defined by the presence of all of the following electrocardiographic criteria: PQ interval duration ≤120 ms, QRS duration ≥120 ms, and presence of δ wave (defined as initial ‘slurring’ of the QRS complex). Ventricular pre-excitation together with the presence of symptoms (orthodromic and/or antidromic atrioventricular reentry tachycardia, atrial fibrillation) defines Wolff–Parkinson–White (WPW) syndrome. The anatomical substrate of ventricular pre-excitation consists of an extranodal accessory atrio-ventricular connection: the so-called Kent bundle. Such pathways can have antegrade, retrograde, or mixed conductive properties. Accessory pathways endowed with anterograde conductive capability may be responsible for manifest, intermittent, or non-manifest ventricular pre-excitation depending on whether it is respectively always visible on the ECG, not always visible on the ECG and not visible on the ECG even though the pathway has the ability to antegrade conduction. The rare phenomenon of supernormal conduction of anomalous pathways is part of the manifest pre-excitation, which represents the topic of the case reported below. Methods and results We report the clinical case of a young not agonist sportsman undergoing an electrophysiological study (SEF) because of he is suffering from ventricular pre-excitation. The SEF did not showed the inducibility of arrhythmias and, at the same time, apparently it showed low risk characteristics of the pathway even during adrenergic stimulus. However, a careful study, performed with atrial stimulation with couplings up to refractoriness of the atrioventricular node revealed supernormal conduction properties of the Kent bundle which proved to have high risk characteristics according to current guidelines and, therefore, was effectively treated with catheter ablation. Conclusions This case invites us to careful studying of accessory pathways properties, especially since, although rare, they may possess supernormal conduction characteristics capable of determining high ventricular rates in the case of sustained atrial tachyarrhythmias, especially in conditions of adrenergic hyperactivity.

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Radiofrequency Catheter Ablation of Left-sided Accessory Atrioventricular Pathways at Atrial Insertion Sites.

University Heart Journal ◽

10.3329/uhj.v8i2.16081 ◽

2013 ◽

Vol 8 (2) ◽

pp. 103-109

Author(s):

Sabina Hashem ◽

Mohsin Hossain ◽

M Atahar Ali ◽

Amal Kumar Choudhury ◽

SM Ahsan Habib ◽

...

Keyword(s):

Catheter Ablation ◽

Radiofrequency Catheter Ablation ◽

Electrophysiological Study ◽

Accessory Pathway ◽

Radiofrequency Energy ◽

Ablation Catheter ◽

Accessory Pathways ◽

Left Posterior ◽

Primary Success ◽

Insertion Sites

Background: This study assessed the efficacy and safety of techniques used to ablate left-sided accessory atrioventricular pathways at atrial insertion sites by retrograde aortic approach. Radiofrequency catheter ablation of left-sided accessory pathways by way of retrograde aortic approach can be highly successful. Methods: This study were done in the department of Cardiology, National Institute of Cardiovascular Diseases (NICVD), Dhaka from June 2009 and March 2010, a total 30 patients with recurrent SVT who has left sided accessory atrioventricular pathways found after electrophysiological study, underwent attempted radiofrequency catheter ablation of one or more accessory atrioventricular pathways by retrograde aortic approach. The ablation catheter was inserted into the femoral artery and passed retrogradely across the aortic valve .Once an optimal target site has been identified, radiofrequency energy at a pre-selected temperature of 55 - 60 0 C and power output set at 50 watts was delivered through the ablation catheter. Loss of preexcitation or interruption of the tachycardia within 5 seconds of RF application was considered effective and RF current was continued in this location 30 to 60 seconds. Ablation success was defined at completion of procedure as acutely successful or unsuccessful on the basis of successful elimination of all ablation targets. Results: During EP study it was found that 9 patients had concealed accessory pathways and 21 had manifest pre-excitation. WPW left-lateral pathway was present in 10 (33.3%), concealed left lateral in 08 (26.7%) ,WPW left posterior in 11 (36.7%), concealed left posterior in 1 (3.3%). Out of 30 accessory pathways, 24 were successfully interrupted with radiofrequency catheter ablation with a primary success rate of 80 %. The ratio of atrial/ ventricular electrogram in successful sites was 0.83 ±0.27 (0.53-1.46). There were no major complications with retrograde aortic approach. Six failed patients were ablated via transseptal method. Conclusion: The retrograde atrial insertion approach to left-sided accessory pathway ablation is very safe and high effective, especially suitable for the failed patients by using retrograde ventricular insertion ablation procedure and by using single-catheter ablation of accessory pathway. DOI: http://dx.doi.org/10.3329/uhj.v8i2.16081 University Heart Journal Vol. 8, No. 2, July 2012

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Dyssynchronous cardiomyopathy in patients with WPW syndrome and its reversibility after RFA of accessory pathway

European Heart Journal ◽

10.1093/eurheartj/ehab724.0359 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

Author(s):

L Svintsova ◽

I Plotnikova ◽

O Dzhaffarova ◽

E Kartofeleva

Keyword(s):

Dilated Cardiomyopathy ◽

Speckle Tracking ◽

Longitudinal Strain ◽

Contractile Function ◽

Accessory Pathway ◽

Holter Monitoring ◽

Rapid Progression ◽

Accessory Pathways ◽

Qrs Duration ◽

Lv Volume

Abstract Introduction In some cases accessory pathway-mediated ventricular preexcitation can be associated with electro-mechanical dyssynchrony and, consequently, with dyssynchrony-related dilated cardiomyopathy, even in the absence of supraventricular tachycardia (SVT). Sometimes rapid progression of ventricular dysfunction developed in such patients after birth. Methods and materials 8 patients with asymptomatic WPW and dyssynchronous cardiomyopathy were examined in our Institute from 2017 till 2019. Four patients of the group were observed in other clinics with dilated cardiomyopathy (DCM) and prescribed appropriate therapy without significant clinical effect. The absence of complaints of heartbeat and episodes of tachycardia at the scheduled Holter monitoring allowed eliminating incessant tachycardia as a possible cause of cardiomyopathy. After radiofrequency ablation (RFA) all patients were performed ECG to assess QRS duration, Holter monitoring, echocardiography (Echo) for assessment of heart chamber volume and left ventricle (LV) contractile function and Speckle tracking – Echo with LV longitudinal strain assessment. The average age of the patients was 9.5 years (from 2 to 14 years). 6 children had heart failure (NYHA Class II). Results According to Echo all patients had widened QRS complex. Dilatation and enlargement of LV volume were marked in 6 pts. According to Echo7 patients had decrease of LV contractile function. According to Speckle tracking – Echo all patients had intraventricular dyssynchrony, decrease of longitudinal strain indices. At intracardiac electrophysiology study right-sided accessory pathways was diagnosed in all patients, successful RFA was performed. Preexitation relapsed, and the repeated RFA was performed in 2 pts. Complications caused by RFA were not marked. After RFA all patients showed a regular normalization of QRS duration. At the 5th day after RFA Echo was performed to all patients. The patients with initially decreased LV ejection fraction had it increased. The patients with initial dilatation and LV volume enlargement had normalization of the given indices. According to Speckle tracking – Echo normalization of global and regional myocardial function, LV longitudinal strain, disappearance of intraventricular and interventricular dyssynchrony were marked in all patients. The index of longitudinal strain was 17,0±0,64% before RFA, after RFA - 23,75±0,92% (p=0,ehab724.035946). Conclusion As a result of RFA of accessory pathways electromechanical resynchronization causes LV demodeling and restoration of its contractile ability. The presented clinical examples are an additional indication for RFA of accessory pathways even in the absence of SVT in patients regardless of age. FUNDunding Acknowledgement Type of funding sources: None.

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Trio of Rheumatic Mitral Stenosis, Right Posterior Septal Accessory Pathway and Atrial Flutter: A Case Report

Journal of Asian Pacific Society of Cardiology ◽

10.15420/japsc.2021.07 ◽

2022 ◽

Vol 1 ◽

Author(s):

Jogendra Singh ◽

Dibyasundar Mahanta ◽

Rudra Pratap Mahapatra ◽

Debasis Acharya ◽

Ramachandra Barik

Keyword(s):

Case Report ◽

Atrial Flutter ◽

Mitral Stenosis ◽

Electrophysiological Study ◽

Accessory Pathway ◽

Atrioventricular Node ◽

Rheumatic Mitral Stenosis ◽

Percutaneous Balloon ◽

Mitral Valvotomy ◽

The Right

A 57-year-old male presented with recurrent palpitations. He was diagnosed with rheumatic mitral stenosis, right posterior septal accessory pathway and atrial flutter. An electrophysiological study after percutaneous balloon mitral valvotomy showed that the palpitations were due to atrial flutter with right bundle branch aberrancy. The right posterior septal pathway was a bystander because it had higher refractory period than atrioventricular node.

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Radiofrequency catheter ablation for supraventricular tachycardia in a paediatric population: characteristics of tachycardia mechanisms in a subpopulation with early onset

Cardiology in the Young ◽

10.1017/s1047951120002954 ◽

2020 ◽

Vol 30 (10) ◽

pp. 1383-1388

Author(s):

Yamina Schibli ◽

Matthias Gass ◽

Florian Berger ◽

Christian Balmer

Keyword(s):

Supraventricular Tachycardia ◽

Early Onset ◽

Late Onset ◽

Electrophysiological Study ◽

Accessory Pathway ◽

Population Characteristics ◽

Common Mechanism ◽

Accessory Pathways ◽

Onset Group ◽

Early Onset Group

AbstractBackground:In children, the first episode of supraventricular tachycardia occurs at various ages. The aim of this study is to describe age-specific tachycardia mechanisms, clinical findings, and outcome in a contemporary cohort of paediatric patients with supraventricular tachycardia.Methods:Retrospective analysis of 531 consecutive patients with structurally normal hearts under the age of 18 years who underwent invasive electrophysiological study for supraventricular tachycardia. The study population was divided into two groups, early-onset group (n = 57) and late-onset group (n = 474), according to the age of the occurrence of the first tachycardia before or after the age of 12 months.Results:Accessory pathway-mediated tachycardia was more common (82.5 versus 50.1%, p < 0.001) and the proportion of left-sided accessory pathways was more pronounced (74.5 versus 53.7%, p = 0.01) in the early-onset group than in the late-onset group. The antegrade and retrograde refractory periods of the accessory pathways were similar in both groups, but pre-excitation was more common in the early-onset group (50.9 versus 31.9%, p = 0.007). Typical atrioventricular nodal re-entrant tachycardia was more common (36.7 versus 7.0%, p < 0.001) in the late-onset group. There was no difference among the two groups regarding overall outcome.Conclusion:Accessory pathway-mediated re-entrant tachycardia is the most common mechanism of recurrent supraventricular tachycardia in infants with structurally normal hearts who are later referred to an electrophysiological study. These pathways often cause pre-excitation and tend to be located on the left side whereas their refractory period is not different from that of patients with late-onset tachycardia.

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Radiofrequency Catheter Ablation of Left-sided Accessory Atrioventricular Pathways at Atrial Insertion Sites

University Heart Journal ◽

10.3329/uhj.v9i1.19507 ◽

2014 ◽

Vol 9 (1) ◽

pp. 18-24

Author(s):

S Hashem ◽

M Hossain ◽

MA Ali ◽

AK Chowdhury ◽

Habib SM Ahsan ◽

...

Keyword(s):

Catheter Ablation ◽

Radiofrequency Catheter Ablation ◽

Electrophysiological Study ◽

Accessory Pathway ◽

Radiofrequency Energy ◽

Ablation Catheter ◽

Accessory Pathways ◽

Left Posterior ◽

Primary Success ◽

Insertion Sites

Background: This study assessed the efficacy and safety of techniques used to ablate left-sided accessory atrioventricular pathways at atrial insertion sites by retrograde aortic approach. Radiofrequency catheter ablation of left-sided accessory pathways by way of retrograde aortic approach can be highly successful. Methods: This study were done in the department of Cardiology, National Institute of Cardiovascular Diseases (NICVD), Dhaka from June 2009 and March 2010, a total 30 patients with recurrent SVT who has left sided accessory atrioventricular pathways found after electrophysiological study, underwent attempted radiofrequency catheter ablation of one or more accessory atrioventricular pathways by retrograde aortic approach. The ablation catheter was inserted into the femoral artery and passed retrogradely across the aortic valve .Once an optimal target site has been identified, radiofrequency energy at a pre-selected temperature of 55 - 60 0 C and power output set at 50 watts was delivered through the ablation catheter. Loss of preexcitation or interruption of the tachycardia within 5 seconds of RF application was considered effective and RF current was continued in this location 30 to 60 seconds. Ablation success was defined at completion of procedure as acutely successful or unsuccessful on the basis of successful elimination of all ablation targets. Results: During EP study it was found that 9 patients had concealed accessory pathways and 21 had manifest pre-excitation. WPW left-lateral pathway was present in 10 (33.3%), concealed left lateral in 08 (26.7%), WPW left posterior in 11 (36.7%), concealed left posterior in 1 (3.3%). Out of 30 accessory pathways, 24 were successfully interrupted with radiofrequency catheter ablation with a primary success rate of 80 %. The ratio of atrial/ ventricular electrogram in successful sites was 0.83 ±0.27 (0.53-1.46). There were no major complications with retrograde aortic approach. Six failed patients were ablated via transseptal method. Conclusion: The retrograde atrial insertion approach to left-sided accessory pathway ablation is very safe and high effective, especially suitable for the failed patients by using retrograde ventricular insertion ablation procedure and by using single-catheter ablation of accessory pathway. DOI: http://dx.doi.org/10.3329/uhj.v9i1.19507 University Heart Journal Vol. 9, No. 1, January 2013; 18-24

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Effect of adenosine on atrioventricular conduction in children and young patients with supraventricular tachycardia

Cardiology in the Young ◽

10.1017/s1047951100003930 ◽

1996 ◽

Vol 6 (4) ◽

pp. 308-314

Author(s):

Parvin C. Dorostkar ◽

Macdonald Dick ◽

Gerald A. Serwer ◽

Sarah LeRoy ◽

Brian Armstrong

Keyword(s):

Supraventricular Tachycardia ◽

Accessory Pathway ◽

Young Patients ◽

Atrioventricular Node ◽

Atrioventricular Conduction ◽

Ventricular Pacing ◽

Accessory Pathways ◽

Before And After ◽

Ventricular Activation ◽

Retrograde Conduction

AbstractAdenosine, when given as an intravenous bolus, has been shown to produce atrioventricular nodal block in humans. To examine the effect of adenosine on conduction across both accessory pathways and the atrioventricular node in children, we reviewed our experience with adenosine administered during both atrial and ventricular pacing in 42 patients with atrioventricular resting tachycardia and in eight patients with atrioventricular nodal reentry tachycardia. Adenosine was administered as a mean bolus of 195 μg/kg/dose during both atrial and ventricular pacing, examining antegrade and retrograde conduction before and after radiofrequency ablation. In those patients with persistent or intermittent pre-excitation, anomalous ventricular activation was either unchanged (n=8) or increased (n=11). Retrograde conduction (either through the accessory pathway alone in three, or across both the accessory pathway and the atrioventricular node in 19) persisted in 92% of the 24 patients studied. Adenosine produced either first or third degree antegrade heart block in all patients studied without pre-excitation (those with either dual atrioventricular nodal pathways or concealed accessory pathways). Adenosine produced retrograde block in all of the eight patients with dual atrioventricular nodal pathways. In contrast, retrograde conduction persisted in 82% (14/17) of patients with concealed accessory pathways (p=0.001). When used to examine retrograde conduction, adenosine was a sensitive (82%) and highly specific (producing retrograde atrioventricular block in all patients with dual atrioventricular nodal pathways) predictor of tachycardia supported by a concealed accessory pathway. Adenosine yielded a sensitivity and specificity of 96% and a positive predictive value of 99.5% for the success of ablation of accessory pathways. These data indicate that the pattern of adenosine-induced changes in either antegrade or retrograde atrioventricular conduction, or conduction in both directions, in young patients with supraventricular tachycardia is related to the mechanism of the tachycardia. Adenosine, therefore, is a useful adjunct in the electrophysiologic evaluation of supraventricular tachycardia in children.

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Characteristics of antegrade-only accessory pathways in children and adolescents

Cardiology in the Young ◽

10.1017/s1047951121000056 ◽

2021 ◽

pp. 1-5

Author(s):

Minh B. Nguyen ◽

Allison C. Hill ◽

Yaniv Bar-Cohen ◽

Michael J. Silka

Keyword(s):

High Risk ◽

Refractory Period ◽

Accessory Pathway ◽

Young Patients ◽

Atrioventricular Node ◽

Effective Refractory Period ◽

Accessory Pathways ◽

Electrophysiology Study ◽

Minimal Data ◽

Subsequent Comparison

Abstract There is minimal data regarding antegrade-only accessory pathways in young patients. Given evolving recommendations and treatments, retrospective analysis of the clinical and electrophysiologic properties of antegrade-only pathways in patients <21 years old was performed, with subsequent comparison of electrophysiology properties to age-matched controls with bidirectional pathways. Of 522 consecutive young patients with ventricular pre-excitation referred for electrophysiology study, 33 (6.3%) had antegrade-only accessory pathways. Indications included palpitations (47%), chest pain (25%), and syncope (22%). The shortest value for either the accessory pathway effective refractory period or the pre-excited R-R interval was taken for each patient, with the median of the antegrade-only group significantly greater than shortest values for the bidirectional group (310 [280–360] ms versus 270 [240–302] ms, p < 0.001). However, the prevalence of pathways with high-risk properties (effective refractory period or shortest pre-excited R-R interval <250 ms) was similar in both study patients and controls (13% versus 21%) (p = 0.55). Sixteen patients had a single antegrade-only accessory pathway and no inducible arrhythmia. Six patients had Mahaim fibres, all right anterolateral with inducible antidromic reciprocating tachycardia. However, 11 patients with antegrade-only accessory pathways and 3 with Mahaim fibres had inducible tachycardia due to a second substrate recognised at electrophysiology study. These included concealed accessory pathways (7), bidirectional accessory pathways (5), and atrioventricular node re-entry (2). Antegrade-only accessory pathways require comprehensive electrophysiology evaluation as confounding factors such as high-risk conduction properties or inducible Supraventricular Tachycardia (SVT) due to a second substrate of tachycardia are often present.

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Radiofrequency catheter ablation for the treatment of supraventricular tachycardias in children and adolescents

Cardiology in the Young ◽

10.1017/s1047951100009689 ◽

2000 ◽

Vol 10 (4) ◽

pp. 376-383 ◽

Cited By ~ 12

Author(s):

Pedro Iturralde ◽

Luís Colín ◽

Sergio Kershenovich ◽

Milton E. Guevara ◽

Argelia Medeiros ◽

...

Keyword(s):

Catheter Ablation ◽

Atrial Flutter ◽

Radiofrequency Catheter Ablation ◽

Accessory Pathway ◽

Atrioventricular Node ◽

Slow Pathway ◽

Accessory Pathways ◽

Children And Young Adults ◽

Supraventricular Tachycardias ◽

Fast Pathway

AbstractWe report our experience in radiofrequency catheter ablation between April, 1992 and December, 1998, in which we treated 287 parients less than 18 years of age (mean 14.3±3.1 years) with supraventricular tachycardia. Accessory pathways were the arrhythmic substrate in 252 of the patients (87.8%), the patients having a total of 265 accessory pathways. Atrioventricular nodal re-entry was the cause of tachycardia in 26 patients (9.0%), while atrial flutter was detected in the remaining 9 patients (3.1%). We were able successfully to eliminate the accessory pathway in 236 patients (89%), but 25 patients had recurrent arrhythmias. Ablation proved successful in all cases of atrioventricular node re-entry tachycardia, the slow pathway being ablated in 25 patients, and the fast pathway in only one case. Recurrence of the arrhythmia occurred in three patients (11.5%). We performed a second ablation in these children, all then proving successful. The ablation was successful in all cases of atrial flutter, with one recurrence (11.1%). Overall, therefore, ablation was immediately successful in 271 patients (94.4%), with a recurrence of the arrhythmia in 29 cases (10.7%). The incidence of serious complications was 2.09% There was one late death due to infective endocarditis, 3 patients suffered complete heart block, 1 had mild mitral regurgitation, and 1 patient developed an haematoma in the groin. We conclude that radiofrequency catheter ablation can now be considered a standard option for the management of paroxysmal supraventricular tachycardias in children and young adults.

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Accessory pathway analysis using a multimodal deep learning model

Scientific Reports ◽

10.1038/s41598-021-87631-y ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Makoto Nishimori ◽

Kunihiko Kiuchi ◽

Kunihiro Nishimura ◽

Kengo Kusano ◽

Akihiro Yoshida ◽

...

Keyword(s):

Deep Learning ◽

Electrophysiological Study ◽

Accessory Pathway ◽

Learning Model ◽

X Rays ◽

X Ray ◽

Wpw Syndrome ◽

Chest X Ray ◽

Deep Learning Model ◽

Ecg Data

AbstractCardiac accessory pathways (APs) in Wolff–Parkinson–White (WPW) syndrome are conventionally diagnosed with decision tree algorithms; however, there are problems with clinical usage. We assessed the efficacy of the artificial intelligence model using electrocardiography (ECG) and chest X-rays to identify the location of APs. We retrospectively used ECG and chest X-rays to analyse 206 patients with WPW syndrome. Each AP location was defined by an electrophysiological study and divided into four classifications. We developed a deep learning model to classify AP locations and compared the accuracy with that of conventional algorithms. Moreover, 1519 chest X-ray samples from other datasets were used for prior learning, and the combined chest X-ray image and ECG data were put into the previous model to evaluate whether the accuracy improved. The convolutional neural network (CNN) model using ECG data was significantly more accurate than the conventional tree algorithm. In the multimodal model, which implemented input from the combined ECG and chest X-ray data, the accuracy was significantly improved. Deep learning with a combination of ECG and chest X-ray data could effectively identify the AP location, which may be a novel deep learning model for a multimodal model.

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