RESUMEN
The ECG of a patient during sinus rhythm shows preexcited QRS pattern, with rS pattern in lead V1, transition in lead V2, and positive inferior leads. Following the stepwise algorithms, the location of accessory pathway (AP) was identified at anteroseptal region. However, the precordial transition in lead V2 indicates mid-septal or posteroseptal AP. The mismatch suggested multiple APs and 5 APs were identified by electrophysiologic study. This case highlights the importance of detailed analysis of ECG in order to achieve adequate ablation.
Asunto(s)
Fascículo Atrioventricular Accesorio , Electrocardiografía , Humanos , Fascículo Atrioventricular Accesorio/fisiopatología , Fascículo Atrioventricular Accesorio/cirugía , Masculino , Ablación por Catéter , Adulto , Femenino , Síndrome de Wolff-Parkinson-White/fisiopatología , Síndrome de Wolff-Parkinson-White/cirugía , Síndrome de Wolff-Parkinson-White/diagnóstico , Diagnóstico DiferencialRESUMEN
BACKGROUND: The anatomy of myocardial fibers around the right cardiac veins (RCVs) and their roles in accessory pathways (APs) are rarely reported. METHODS: Six RCV-APs were identified from 566 patients with right-sided APs. Mapping of retrograde atrial activation was performed using CARTO 3 system under orthodromic tachycardia or right ventricular pacing. Venography of RCVs was acquired at the earliest retrograde atrial activation. RESULTS: Patients enrolled had a median age of 30 (11-51) years, 5 of them were male. Venography of RCVs could be classified into 3 distinct patterns based on the identified ventricular branches, right marginal vein only (type I; n=3), both right marginal vein and anterior cardiac veins (type II; n=2), and anterior cardiac vein only (type III; n=1). Patients with type I venography had rS QRS pattern in lead V1, negative delta wave in lead III and negative or isoelectric delta wave in lead aVF. However, patients with type II and III venography had QS QRS patterns in lead V1 and variable patterns of delta wave in inferior leads. Earliest retrograde atrial activation was found at a median of 16.75 (14.60-20.00) mm away from the tricuspid annulus, all with A larger than V. At the earliest retrograde atrial activation, far-field ventricular electrogram was found 30 ms later than QRS onset in 1 patient under sinus rhythm. AP conduction was eliminated by mechanical pressure in 2 and by radiofrequency ablation in 4 at the ostium of the veins colocalizing with the earliest retrograde activation of the right atrium. No recurrence was observed during 36 (10-60) months follow-up. CONCLUSIONS: The RCV-AP is a rare form of right-sided APs characterized by atrial insertions distant from the annulus. ECG-speculated ventricular insertion sites conformed to the location of identified RCVs.
Asunto(s)
Fascículo Atrioventricular Accesorio , Ablación por Catéter , Flebografía , Humanos , Masculino , Adulto , Femenino , Persona de Mediana Edad , Fascículo Atrioventricular Accesorio/fisiopatología , Fascículo Atrioventricular Accesorio/cirugía , Adolescente , Adulto Joven , Niño , Técnicas Electrofisiológicas Cardíacas , Vasos Coronarios/fisiopatología , Vasos Coronarios/diagnóstico por imagen , Potenciales de Acción , Frecuencia Cardíaca , Estimulación Cardíaca ArtificialRESUMEN
BACKGROUND: T-wave memory (TWM) is a rare cause of T-wave inversion (TWI). Alterations in ventricular activation due to abnormal depolarization may cause repolarization abnormalities on the ECG, even if myocardial conduction returns to normal. These repolarization changes are defined as TWM. In our study, we aimed to determine the frequency of TWM development and the predictors affecting it in the pediatric population who underwent accessory pathway (AP) ablation due to Wolff-Parkinson-White (WPW) syndrome. METHODS: The data of patients with manifest AP who underwent electrophysiological studies and ablation between 2015 and 2021 were retrospectively analyzed. The study included 180 patients who were under 21 years of age and had at least one year of follow-up after ablation. Patients with structural heart disease, intermittent WPWs, recurrent ablation, other arrhythmia substrates, and those with less than one-year follow-up were excluded from the study. The ECG data of the patients before the procedure, in the first 24 h after the procedure, three months, and in the first year were recorded. The standard ablation technique was used in all patients. RESULTS: Postprocedure TWM was observed in 116 (64.4%) patients. Ninety-three patients (51.7%) had a right-sided AP, and 87 patients (48.3%) had a left-sided AP. The presence of posteroseptal AP was found to be significantly higher in the group that developed TWM. Of these patients, 107 (93.1%) patients showed improvement at the end of the first year. Preprocedural absolute QRS-T angle, postprocedural PR interval, and right posteroseptal pathway location were identified as predictors of TWM. CONCLUSION: The development of TWM is particularly associated with the right-sided pathway location, especially the right posteroseptal pathway location. The predictors of TWM are the preprocedural QRS-T angle, the postprocedural PR interval, and the presence of the right posteroseptal AP.
Asunto(s)
Fascículo Atrioventricular Accesorio , Ablación por Catéter , Electrocardiografía , Síndrome de Wolff-Parkinson-White , Humanos , Síndrome de Wolff-Parkinson-White/cirugía , Síndrome de Wolff-Parkinson-White/fisiopatología , Masculino , Femenino , Estudios Retrospectivos , Ablación por Catéter/métodos , Fascículo Atrioventricular Accesorio/cirugía , Fascículo Atrioventricular Accesorio/fisiopatología , Adolescente , Niño , Adulto JovenRESUMEN
AIMS: Radiofrequency ablation is used as a first-line therapy for accessory pathways (APs). However, data regarding the effects of pulsed field ablation (PFA) on APs are limited. We sought to evaluate the acute procedural and 6-month success and safety of PFA in a cohort of patients with APs. METHODS AND RESULTS: A focal contact force-sensing PFA catheter was used for patients with APs. Pulsed field ablation generator generated a bipolar and biphasic waveform (±1000â V) with a duration of 100â ms from the tip of the PFA catheter. A 100% acute procedural success was achieved in 10 conscious patients with APs (7 left anterolateral, 2 left inferolateral, and 1 right posteroseptal APs) including 6 (60%) patients after an initial application. The average total ablation time was 6.3 ± 4.9â s for 4.7 ± 1.8 ablation sites (ASs), including 3.1 ± 2.4â s at targets and 3.2 ± 2.9â s at 3.2 ± 2 bolus ASs. The mean skin-to-skin time was 59.3 ± 15.5â min, and PFA catheter dwell time was 29.4 ± 7.8â min. One patient encountered transient sinus arrest during PFA due to parasympathetic overexcitation. Sinus rhythm was restored in all patients without any significant adverse events during the short-term follow-up. CONCLUSION: Pulsed field ablation of APs was feasible, effective, and safe. Its efficiency was remarkable for its ultrarapid termination of AP conduction. Further studies are warranted to prove whether utilization of PFA with current parameters can extend to manifold AP ablation.
Asunto(s)
Fascículo Atrioventricular Accesorio , Ablación por Catéter , Humanos , Proyectos Piloto , Femenino , Masculino , Fascículo Atrioventricular Accesorio/cirugía , Fascículo Atrioventricular Accesorio/fisiopatología , Resultado del Tratamiento , Adulto , Ablación por Catéter/métodos , Ablación por Catéter/efectos adversos , Persona de Mediana Edad , Adulto Joven , Factores de Tiempo , Frecuencia Cardíaca , Adolescente , Catéteres CardíacosRESUMEN
In 1930, Wolff, Parkinson and White described the syndrome that bears their names. The mechanisms of supraventricular tachycardias were analyzed by brilliant electrocardiography interpretation by Pick and Langendorf. Wellens and Durrer using electrophysiologic studies analyzed the tachycardia mechanism invasively. In Germany the group by Seipel and Breithardt as well as Neuss and Schlepper studied the tachycardia mechanisms and response to antiarrhythmic drugs invasively by electrophysiological studies. Following the first successful interruption of an accessory pathway by Sealy in 1967, surgeons and electrophysiologists cooperated in Germany. Two centers, Hannover and Düsseldorf were established. Direct current (DC) ablation of accessory pathways was introduced by Morady and Scheinman. Because of side effects induced by barotrauma of DC, alternative strategies were studied. In 1987, radiofrequency ablation was introduced and thereafter established as curative therapy of accessory pathways in all locations.
Asunto(s)
Fascículo Atrioventricular Accesorio , Ablación por Catéter , Síndromes de Preexcitación , Taquicardia Supraventricular , Síndrome de Wolff-Parkinson-White , Humanos , Síndrome de Wolff-Parkinson-White/diagnóstico , Síndrome de Wolff-Parkinson-White/cirugía , Síndromes de Preexcitación/diagnóstico , Síndromes de Preexcitación/terapia , Taquicardia Supraventricular/cirugía , Taquicardia/cirugía , Fascículo Atrioventricular Accesorio/diagnóstico , Fascículo Atrioventricular Accesorio/cirugía , ElectrocardiografíaAsunto(s)
Cardiomiopatías , Ablación por Catéter , Insuficiencia Cardíaca , Humanos , Ablación por Catéter/efectos adversos , Insuficiencia Cardíaca/cirugía , Cardiomiopatías/cirugía , Cardiomiopatías/complicaciones , Masculino , Femenino , Persona de Mediana Edad , Adulto , Fascículo Atrioventricular Accesorio/cirugía , Fascículo Atrioventricular Accesorio/fisiopatologíaRESUMEN
BACKGROUND: Accurate estimation of accessory pathway (AP) localization in patients with ventricular pre-excitation or Wolff-Parkinson-White (WPW) syndrome remains a diagnostic challenge. Existing algorithms have contributed significantly to this area, but alternative algorithms can offer additional perspectives and approaches to AP localization. OBJECTIVE: This study introduces and evaluates the diagnostic accuracy of the EPM algorithm in AP localization, comparing it with established algorithms Arruda and EASY. METHODS: A retrospective analysis was conducted on 138 patients from Hospital São Paulo who underwent catheter ablation. Three blinded examiners assessed the EPM algorithm's diagnostic accuracy against the Arruda and EASY algorithms. The gold standard for comparison was the radioscopic position of the AP where radiofrequency ablation led to pre-excitation disappearance on the ECG. RESULTS: EPM showed a diagnostic accuracy of 51.45%, closely aligning with Arruda (53.29%) and EASY (44.69%). Adjacency accuracy for EPM was 70.67%, with Arruda at 66.18% and EASY at 72.22%. Sensitivity for EPM in distinguishing left vs. right APs was 95.73%, with a specificity of 74.33%. For identifying septal vs. lateral right APs, EPM sensitivity was 82.79% with a specificity of 46.15%. These measures were comparable to those of Arruda and EASY. Inter-observer variability was excellent for EPM, with Kappa statistics over 0.9. CONCLUSION: The EPM algorithm emerges as a reliable tool for AP localization, offering a systematic approach beneficial for therapeutic decision-making in electrophysiology. Its comparable diagnostic accuracy and excellent inter-observer variability underscore its potential clinical applicability. Future research may further validate its efficacy in a broader clinical setting.
Asunto(s)
Fascículo Atrioventricular Accesorio , Algoritmos , Electrocardiografía , Sensibilidad y Especificidad , Síndrome de Wolff-Parkinson-White , Humanos , Fascículo Atrioventricular Accesorio/fisiopatología , Fascículo Atrioventricular Accesorio/cirugía , Masculino , Femenino , Síndrome de Wolff-Parkinson-White/fisiopatología , Síndrome de Wolff-Parkinson-White/cirugía , Síndrome de Wolff-Parkinson-White/diagnóstico , Estudios Retrospectivos , Adulto , Ablación por Catéter , Reproducibilidad de los Resultados , Síndromes de Preexcitación/fisiopatología , Síndromes de Preexcitación/diagnóstico , Persona de Mediana EdadRESUMEN
BACKGROUND: Ablation of accessory pathways (APs) is the cornerstone for treatment of patients with Wolff-Parkinson-White syndrome and manifestation of atrioventricular reentrant tachycardia. Pulsed field ablation (PFA) is a new type of nonthermal energy source delivered to the underlying tissue via the ablation catheter and used for ablation of arrhythmic substrates. OBJECTIVE: The purpose of this study was to determine the efficiency and long-term outcome of ablation of APs of different localizations using a focal pulsed electrical field. METHODS: Electrophysiological study was performed in patients with indication for AP ablation. An ablation catheter was used to map the position of AP insertion. Pulsed electric field was delivered through a standard ablation catheter. In left-sided APs, the first ablation attempt was within the coronary sinus (CS). Patient follow-up was scheduled 1-3 months after the ablation. Additional check-up was performed after 6 and 12 months. RESULTS: Fourteen 14 patients (3 pediatric) were treated. Termination of AP conduction was achieved in all procedures. The cohort consisted of 3 right free wall, 3 posteroseptal, and 8 left-sided APs. Ablation through CS was successfully used in 7 of 8 patients with left-sided APs. No complications were reported. Median follow-up was 5.5 months. Conduction recurrence through AP was documented in 1 patient. CONCLUSION: Focal PFA for AP shows promising results in terms of efficacy and safety. A high rate of successful termination of left-sided APs by ablation within CS may represent a new standard approach. The safety and efficacy profile of PFA seems to be transferable to the pediatric population.
Asunto(s)
Fascículo Atrioventricular Accesorio , Ablación por Catéter , Síndrome de Wolff-Parkinson-White , Humanos , Masculino , Femenino , Ablación por Catéter/métodos , Fascículo Atrioventricular Accesorio/cirugía , Fascículo Atrioventricular Accesorio/fisiopatología , Adulto , Síndrome de Wolff-Parkinson-White/cirugía , Síndrome de Wolff-Parkinson-White/fisiopatología , Resultado del Tratamiento , Adolescente , Persona de Mediana Edad , Niño , Estudios de Seguimiento , Taquicardia por Reentrada en el Nodo Atrioventricular/cirugía , Taquicardia por Reentrada en el Nodo Atrioventricular/fisiopatología , Taquicardia por Reentrada en el Nodo Atrioventricular/diagnóstico , Adulto Joven , Electrocardiografía , Sistema de Conducción Cardíaco/fisiopatología , Técnicas Electrofisiológicas Cardíacas/métodosRESUMEN
BACKGROUND: Posteroseptal accessory pathways (APs) associated with coronary sinus (CS) diverticulum present a rare and challenge for ablation. This study aimed to compare the safety and efficacy of conventional approach and three-dimensional (3D) mapping system in the catheter ablation. METHODS AND RESULTS: This was a retrospective study of all patients (from January 2013 to July 2022) who underwent catheter ablation of posteroseptal AP associated with CS diverticula in our center. Patients who underwent catheter ablation using the traditional fluoroscopy method were included in the conventional method group (n = 13). Patients who underwent catheter ablation using the 3D mapping method were included in the 3D mapping group (n = 11). Clinical characteristics, ablation procedure, and outcomes were recorded and analyzed between the two groups. Out of 669 patients with posteroseptal APs, 24 of them (3.6%) were associated with CS diverticula. All patients in both groups successfully completed the electrophysiological study. In the conventional method group, two patients experienced complications (one patient with pericardial effusion and the other patient with femoral arterial hematoma), and two patients had recurrence. However, no patients suffered from complications or recurrence during follow-up. The procedure time and fluoroscopy time in the conventional method group were significantly longer than those in the 3D mapping method group. CONCLUSIONS: The utilization of 3D mapping led to reduced fluoroscopy time, shorter procedure duration, enhanced acute success rates, and decreased incidence of complications.