THE ROLE OF DIGOXIN IN THE SUCCESSFUL TERMINATION OF A RESISTANT MATERNAL ATYPICAL AV NODAL REENTRY TACHYCARDIA

Here, we describe the case of a patient during her gestational period with resistant tachycardia that failed front line treatment options and was treated using an older agent.

LEFT FREE WALL-SIDED MAHAIM TYPE FIBER AND AV NODAL REENTRY TACHYCARDIA -- UNUSUAL BUT NOT IMPOSSIBLE COMBINATION

A 52-year-old patient with previous catheter ablation of AV nodal reentrant tachycardia (AVNRT) had a redo procedure for reported recurrence. During the study AVNRT was not inducible, but a previously unrecognized left-sided Mahaim type accessory pathway was diagnosed and ablated successfully.

Importance of the Activation Sequence of the His or Right Bundle for Diagnosis of Complex Tachycardia Circuits

In this review, we emphasize the unique value of recording the activation sequence of the His bundle or right bundle branch (RB) for diagnoses of various supraventricular and fascicular tachycardias. A close analysis of the His to RB (H-RB) activation sequence can help differentiate various forms of supraventricular tachycardias, namely atrioventricular nodal reentry tachycardia from concealed nodofascicular tachycardia, a common clinical dilemma. Furthermore, bundle branch reentry tachycardia and fascicular tachycardias often are included in the differential diagnosis of supraventricular tachycardia with aberrancy, and the use of this technique can help the operator make the distinction between supraventricular tachycardias and these other forms of ventricular tachycardias using the His-Purkinje system. We show that this technique is enhanced by the use of multipolar catheters placed to span the proximal His to RB position to record the activation sequence between proximal His potential to the distal RB potential. This allows the operator to fully analyze the activation sequence in sinus rhythm as compared to that during tachycardia and may help target ablation of these arrhythmias. We argue that 3 patterns of H-RB activation are commonly identified—the anterograde H-RB pattern, the retrograde H-RB (right bundle to His bundle) pattern, and the chevron H-RB pattern (simultaneous proximal His and proximal RB activation)—and specific arrhythmias tend to be associated with specific H-RB activation sequences. We show that being able to record and categorize this H-RB relationship can be instrumental to the operator, along with standard pacing maneuvers, to make an arrhythmia diagnosis in complex tachycardia circuits. We highlight the importance of H-RB activation patterns in these complex tachycardias by means of case illustrations from our groups as well as from prior reports.

Ventricular tachycardia?

A 59-year-old patient presented with “suspicion of ventricular tachycardia” because of “abnormalities in the long-term ECG” (Figure. 1). Cryoablation of the slow path had already taken place beforehand, in the case of slow-fast atrioventricular nodal reentry tachycardia.

Quality of Life after Ablation vs Medication Therapy in Patients With Supraventricular Tachycardia

Objective: Supraventricular tachycardia (SVT) is the most common presentation of patients at cardiac emergency department. This study aims to determine the quality of life in patients with supraventricular tachycardia after they treated with medicines vs. ablation therapy. Methods: This prospective clinical comparative study was held at the National Institute of Cardiovascular Diseases (NICVD). Patients 18 years or older of either gender presenting with the two most common variants of SVT i.e. Atrioventricular nodal reentry tachycardia (AVNRT) and Atrioventricular reentry tachycardia (AVRT) were eligible to be included into the study. Once stabilized at the emergency department (ED) the patients were given the option to undergo electrophysiology study and radiofrequency ablation (EPS and RFA) (group A) or opt for medications only (group B). Quality of life (sense of personal well being, impact on social life, fear of mortality or anxiety about the disease, recurrence of episodes of arrhythmia, and visits to ED) was assessed through a questionnaire filled after six months of receiving treatment. Results: A total of 120 patients were included into our study. Group A and group B were evenly divided with 60 patients each. The overall mean age of the participants and duration of cardiac illness were 44.67±18.91 and 5.42±3.13 years, respectively. Patients who received EPS and RFA (group A) had superior and statistically significant scores (better QoL) for sense of personal well being, impact on social life, fear of mortality or anxiety levels, recurrence of arrhythmia, and visits to the ED as compared to those who received medications alone, p<0.05. Conclusion: EPS and RFA vastly improved the quality of life in patients with SVT post treatment. Medications alone are associated with a high number of post treatment sequels and adverse events; therefore they are best avoided in patients with SVT.

Voltage bridge mapping in atrioventricular nodal reentry tachycardia ablation in adult population: results from a multicenter registry

Funding Acknowledgements Type of funding sources: None. Background The presence of Low Voltage Bridge (LVB) in Atrioventricular Nodal Reentry Tachycardia (AVNRT) ablation has been described in children populations. Slow pathway ablations visualizing and targeting the LVB has been described to be safe and effective. However, the incidence of LVB in AVNRT ablation has not been widely explored in adult population. Purpose We aim to investigate the presence of LVB in adult patients (pts) undergoing AVNRT ablation, and the relationship between the LVB and the successful ablation site. We have also investigated the correlations between the Koch’s triangle (KT) anatomy and biophysical pts data. Methods The observational registry prospectively collected data of 165 pts. undergoing AVNRT ablation guided by 3D electroanatomical mapping system (EnSite - Abott, St Paul, MN) in 6 EP centers. Gender: 90F – 75M (55% - 45%) - Age: 57 ± 17 ys (min 15 – max 87) - Weight: 73 ± 15 kgs (min 42 - max 150) Prior of ablation a voltage map of KT was created using diagnostic and ablation catheters. We define as Type I LVB a clear, long area of low voltage within the KT between the CS ostium and the AV node with the base on the edge of the tricuspid annulus and Type II LVB a narrow low voltage channel between normal-voltage regions with the base on the edge of the tricuspid annulus. The relationship between LVB and successful site was evaluated at the end of the procedure. KT anatomical data were correlated to gender, age and weight. Results The LVB was identified in 134 pts (81%) with a prevalence of type I (91 - 68%) over type II (33 - 25%). In 10 pts (7%) the LVB did not match type I nor type II. When an LVB was identified, the correspondence between the LVB and the successful ablation site was verified in 117 pts (87%). In addition, a shorter RF time was applied when an LVB was found (396s vs 298s; p = 0.03). Strong correlations between KT anatomy and biophysical pts data were not identified. The distance between His electrograms and the successful ablation site weakly correlated (ρ = -0.24, p &lt; 0.01) with pts age suggesting a shortening in the distance with age progression. Conclusion The visualization of the Low Voltage Bridge may be a helpful tool to guide AVNRT ablation in a large cohort of pts; furthermore it is associated with reduced RF applications time. The KT characteristics are difficult to be predicted a priori according to patient gender, age or weight.