Occurrence of Potentially Lethal Arrhythmia due to Sudden Exposure of an Overt Accessory Pathway 8 Years After Catheter Ablation of a Concealed Accessory Pathway.

Although the efficacy of catheter ablation of the accessory pathway (AP) has been established, there are subgroups of APs with an intermittent conduction property, which is sometimes difficult to diagnose accurately. A 57-year-old man with a history of catheter ablation was referred to our clinic due to frequent faintness. He had undergone concealed AP ablation 8 years previously and bilateral circumferential pulmonary vein isolation (CPVI) 6 years previously. During regular electrocardiogram monitoring, it was suggested that irregular wide QRS tachycardia, which was considered to be atrial fibrillation with antegrade AP conduction, was the cause of the present symptoms. In the present electrophysiological study, we noticed a residual antegrade AP in the left lateral wall that was not observed during the previous session. We achieved abolition of overt accessory conduction, bilateral CPVI, and superior vena cava isolation with several radiofrequency applications without any recurrence. We also confirmed the absence of dormant conduction in the AP and the left atrium-PV connection with 20 mg adenosine triphosphate. This case demonstrated the possibility of sudden exposure of overt AP conduction late after catheter ablation of the concealed AP and the importance of confirming the absence of dormant conduction by means of adenosine triphosphate, which has the potential benefit of revealing latent AP conduction.

Cause of the "power-on reset" phenomenon other than electric magnetic interference in a patient with a pacemaker.

A 67-year old male with a dual-chamber pacemaker visited for a regular check-up. An unfamiliar message emerged on the display just after placing the programmer wand. We could recognize that the pacemaker had already been in the safe back-up mode of DDI, and the programmer prompted a re-initialization request. We are so surprised because there was no indication of device malfunction the day before in daily monitoring and a 12-lead electrocardiogram revealed normally working in the DDD mode just before checking the device. The pacemaker was immediately re-programmed to the former setting. This phenomenon has not recurred for 12 months.

Applicability of 3-Dimensional Quantitative Coronary Angiography-Derived Computed Fractional Flow Reserve for Intermediate Coronary Stenosis.

BACKGROUND: Quantitative flow ratio (QFR) is a newly developed image-based index for estimating fractional flow reserve (FFR).Methods and Results:We analyzed 151 coronary arteries with intermediate stenosis in 142 patients undergoing wire-based FFR measurement using dedicated software. Predefined contrast flow QFR, which was derived from 3-dimensional quantitative coronary angiography (3-D QCA) withThrombolysis in Myocardial Infarction (TIMI) frame counts, was compared with FFR as a reference. QFR had good correlation (r=0.80, P<0.0001) and agreement (mean difference: 0.01±0.05) with FFR. After applying the FFR cut-off ≤0.8, the overall accuracy rate of QFR ≤0.8 was 88.0%. On receiver operating characteristics analysis, the area under the curve was 0.93 for QFR. In contrast, 3-D QCA-derived anatomical indices had insufficient correlation with FFR and diagnostic performance compared with QFR. CONCLUSIONS: QFR had good correlation and agreement with FFR and high diagnostic performance in the evaluation of intermediate coronary stenosis, suggesting that QFR may be an alternative tool for estimating myocardial ischemia.

Automatic analyzer for highly polar carboxylic acids based on fluorescence derivatization-liquid chromatography.

A sensitive, versatile, and reproducible automatic analyzer for highly polar carboxylic acids based on a fluorescence derivatization-liquid chromatography (LC) method was developed. In this method, carboxylic acids were automatically and fluorescently derivatized with 4-(N,N-dimethylaminosulfonyl)-7-piperazino-2,1,3-benzoxadiazole (DBD-PZ) in the presence of 4-(4,6-dimethoxy-1,3,5-triazin-2-yl)-4-methylmorpholinium chloride by adopting a pretreatment program installed in an LC autosampler. All of the DBD-PZ-carboxylic acid derivatives were separated on the ODS column within 30 min by gradient elution. The peak of DBD-PZ did not interfere with the separation and the quantification of all the acids with the exception of lactic acid. From the LC-MS/MS analysis, we confirmed that lactic acid was converted to an oxytriazinyl derivative, which was further modified with a dimethoxy triazine group of 4-(4,6-dimethoxy-1,3,5-triazin-2-yl)-4-methylmorpholinium chloride (DMT-MM). We detected this oxytriazinyl derivative to quantify lactic acid. The detection limits (signal-to-noise ratio = 3) for the examined acids ranged from 0.19 to 1.1 µm, which correspond to 95-550 fmol per injection. The intra- and inter-day precisions of typical, highly polar carboxylic acids were all <9.0%. The developed method was successfully applied to the comprehensive analysis of carboxylic acids in various samples, which included fruit juices, red wine and media from cultured tumor cells.

Radial artery cannulation decreases the distal arterial blood flow measured by power Doppler ultrasound.

Radial arterial cannulation is a popular technique for continuous hemodynamic monitoring in an area of anesthesia and intensive care. Although the risk for invasive monitoring is considerable, there is scarce information about the change in blood flow of cannulated vessel after the catheterization. In the current investigation, we evaluated the change in the cannulated arterial blood flow. Six volunteers (study 1) and eight post-surgical patients (study 2) were enrolled into the studies. In the study 1, the both side of diameter of radial artery (RA), ulnar artery (UA) and dorsal branch of radial artery (DBRA) of participants were measured using power Doppler ultrasound (PDU) with or without proximal oppression. In the study 2, the diameter of RA, UA and DBRA of the both intact and cannulated side were compared. Study 1: The diameter of RA was 3.4 (0.52) [mean (SD)] mm and the proximal oppression significantly decreased the diameter to 1.8 (0.59) mm. The diameter of DBRA measured by PDU also decreased 2.0 (0.60)-1.3 (0.59) mm. Study 2: There was no difference between the diameters of right and left RA, however, the UA was larger [3.4 (0.60) vs. 2.8 (0.83) mm] and the DBRA was narrower [1.4 (0.43) vs. 2.0 (0.47) mm] in the cannulated side. The diameters of DBRA were different between the intact and cannulated side in the patients. Although there is no information of relationships between cause of severe complication and decreased flow, significant reduction of blood flow should be concerned.

Nonocclusive mesenteric ischemia following multiple wasp stings.

Massive wasp envenomation can cause not only severe immediate allergic reactions and anaphylaxis but also severe delayed toxin-mediated systemic reactions, including hemolysis, coagulopathy, rhabdomyolysis, acute renal failure, and hepatotoxicity. However, reports of the latter type of reactions are rare. The subject of this case report, a 66-year-old man, was stung more than 30 times during an attack by wasps. Although he initially complained of pain, he showed no signs of anaphylaxis during observation in an emergency department. Twenty hours after envenomation, he was admitted to the hospital because of vomiting, abdominal pain, and lower gastrointestinal bleeding. Mesenteric ischemia, rhabdomyolysis, acute renal failure, and hepatotoxicity were diagnosed as delayed toxin-mediated systemic reactions resulting from massive wasp envenomation. Contrast-enhanced computed tomography findings, which included no thrombi or emboli but did reveal the abrupt tapering of mesenteric arteries, strongly suggested that the ischemia was due to nonocclusive mesenteric ischemia. Immediately after diagnosis, an emergency laparotomy was performed. Nonocclusive mesenteric ischemia was finally diagnosed via a histologic examination of the resected small bowel. We present the first case report of nonocclusive mesenteric ischemia consequent to wasp stings.

Adverse clinical events after percutaneous coronary intervention in very elderly patients with acute coronary syndrome.

The number of very elderly patients with acute coronary syndrome (ACS) is increasing. Therefore, owing to the need for evidence-based treatment decisions in this population, this study aimed to examine the clinical outcomes during 1 year after percutaneous coronary intervention (PCI) in very elderly patients with ACS. This prospective multicenter observational study comprised 1337 patients with ACS treated with PCI, classified into the following four groups according to age: under 60, <60 years; sexagenarian, ≥60 and <69 years; septuagenarian, ≥70 and <80 years; and very elderly, ≥80 years. The primary endpoint was a composite of the first occurrence of all-cause death, nonfatal myocardial infarction, nonfatal stroke, and bleeding within 1 year after PCI. We used the sexagenarian group as a reference and compared outcomes with those of the other groups. The incidence of the primary endpoint was significantly higher in the very elderly group than in the sexagenarian group (36 [12.7%] vs. 24 [6.9%], respectively; hazard ratio, 1.94; 95% confidence interval: 1.16-3.26; p = 0.012). The higher incidence of the primary endpoint was primarily driven by a higher incidence of all-cause death. When the multivariable analysis was used to adjust for patient characteristics and comorbidities, no difference was observed in the primary endpoint between the very elderly and sexagenarian groups (p = 0.96). The incidence of adverse events after PCI, particularly all-cause death, in very elderly patients with ACS was high. However, if several confounders are adjusted, comparable outcomes may be expected within 1 year after PCI among this population.

Connexin-43 hemichannels contribute to the propagation of µ-calpain-mediated neuronal death in a cortical ablation injury model.

We investigated the role of the astrocytic and neuronal hemichannels (HCs) in the spread of cortical neuronal death in a rat cortical injury model. Over time (by 6 h), propidium iodide (PI)-positive cells with labeling either with anti-neuron specific enolase or anti-parvalbumin (indicating GABAnergic interneurons) antibody spread in the deep cortical layers adjacent to the injury and co-localized with activated µ-calpain. Connexin (Cx)-43, glial fibrillary acidic protein (GFAP), activated µ-calpain and α-fodrin breakdown product (FBP) increased post-injury, peaking at 1 h, in the injury and adjacent areas. GFAP-Cx43-positive reactivated astrocytes exhibited similar distribution to the dead neurons. Cx43 and Cx36 primarily comprise HCs in the astrocyte and neuron, respectively. Ethidium bromide (EtBr) uptake was enhanced post-injury, and confirmed in the Cx43- and Cx36-positive cells. A Cx43-HC inhibitor Gap26 prevented the opening of the Cx43-HC and Cx36-HC, µ-calpain activation, α-fodrin proteolysis and death in the deep cortical neurons. Collectively, opening of the astrocytic Cx43-HC and neuronal Cx36-HC would induce the regional spread of cortical neuronal death through µ-calpain activation in the rat brain injury model.

Dress-up chiral columns for the enantioseparation of amino acids based on fluorous separation.

In this paper, we report a new type of chiral high-performance liquid chromatography (HPLC) column--a so-called dress-up chiral column--featuring a chiral stationary phase adsorbed reversibly in a commercial fluorous HPLC column through fluorous interactions. We synthesized perfluroalkylated proline derivatives as chiral stationary phase compounds and then adsorbed them reversibly in the fluorous HPLC column through the pumping of their solutions. By using this dress-up chiral column and fluorophobic elution of an aqueous copper(II) sulfate/MeOH mixture, we could enantioseparate seven racemic amino acids within 40 min. When we washed the dress-up chiral column with fluorophilic tetrahydrofuran or MeOH, the adsorbed chiral stationary phase compounds desorbed from the column, completely destroying its enantioseparation ability. The relative standard deviation of the retention times, the number of theoretical plates, and the resolution for each of four preparations of the dress-up columns were all less than or equal to 9.53% in 20-times repeated analysis, and were all less than or equal to 18.7% in four different preparations, respectively.

Left ventricular free wall perforation by a right ventricular pacemaker lead: a case report.

BACKGROUND: Lead perforation is one of the major complications of pacemaker implantation, but cases of right ventricular (RV) lead perforation through the septum and left ventricle are rarely reported. We described a rare case of left ventricular (LV) free wall perforation by an RV lead and the management of this complication. CASE SUMMARY: An 84-year-old man was admitted with a dual-chamber pacemaker due to pacing failure caused by an RV lead fracture. New lead implantation was performed on the next day, but pacing failure occurred again on the second post-operative day (POD). We found the lead perforation on the fluoroscopy during temporary pacemaker insertion. Computed tomography scan and transthoracic echocardiogram showed that the added lead perforated through both the septum and LV free wall. A new lead was inserted on the fourth POD, and an off-pump open chest surgery for extraction of the penetrating lead was performed uneventfully on the 20th POD. DISCUSSION: We considered that some features of the lead (SelectSecure 3830-69, Medtronic) may be related to this complication, as the lead was very thin, had a non-retractable bare screw and was inserted with a dedicated delivery catheter. We have to be careful when performing implantation of this kind of lead to avoid such a rare complication.

[Inadvertent thoracic duct puncture during right axially central venous cannulation].

A case of inadvertent thoracic duct puncture during right axially central venous cannulation is reported. The catheterization was performed under the real time ultrasound guidance technique and the coronal view image was continuously displayed. After confirming the feelings of venous puncture, clear yellow fluid was aspired into the connected syringe to the needle. Initially, an accidental thoracic puncture with subsequent pleural fluid aspiration was suspected;however, no finding of pleural effusion was observed with ultrasound imaging and computed tomography. Thus, an accidental thoracic duct puncture and the subsequent lymph fluid aspiration were suspected. Even in a right side approach for central venous catheterization, thoracic duct injury might ensure.

Honeycomb-like structure in spontaneous recanalized coronary thrombus demonstrated by serial angiograms: a case report.

BACKGROUND: The honeycomb-like structure (HLS) is a rare cause of myocardial ischaemia characterized by multiple communicating channels divided by thin septa. The aetiology of this specific structure remains speculative. CASE SUMMARY: A 55-year-old man was admitted due to worsening effort angina during the previous 2 months. Diagnostic coronary angiography revealed occlusion of the distal right coronary artery (RCA) with good collateral flow from the left coronary artery. We considered this lesion as a recent total occlusion, and planned a percutaneous coronary intervention (PCI). At the time of PCI, 7 days after admission, an angiogram showed a spontaneous recanalization of the occlusive RCA. Intravascular ultrasound (IVUS) depicted a HLS at the recanalized lesion, including atherosclerotic stenosis. We managed these lesions with drug-eluting stents. DISCUSSION: A recanalized thrombus may manifest as a HLS. In this case, the patient suffered from worsening effort angina during the previous 2 months, we confirmed a spontaneous recanalization of the occluded coronary lesion by serial angiographic images, and observed HLS adjacent to the atherosclerotic attenuated plaque by using high-resolution IVUS. Recanalized organizing thrombus is considered an entity of HLS. However, all previous studies on the HLS in vivo have detected the structure in an already recanalized state. Therefore, the aetiology remained speculative and evidence has been indirect. This present case demonstrates that recanalized atherosclerotic thrombosis might be one of the causes of HLS.

Relationship Between Platelet Reactivity and Ischemic and Bleeding Events After Percutaneous Coronary Intervention in East Asian Patients: 1-Year Results of the PENDULUM Registry.

Background The balance between ischemic and bleeding events and their association with platelet reactivity in patients receiving antiplatelet therapy after percutaneous coronary intervention (PCI), which differs among regions, is not fully evaluated for East Asians. We examined ischemic/bleeding events and platelet reactivity in Japanese patients undergoing PCI and determined associations between high/low platelet reactivity and clinical outcomes. Methods and Results PENDULUM (Platelet Reactivity in Patients with Drug Eluting Stent and Balancing Risk of Bleeding and Ischemic Event) is a prospective, multicenter registry of Japanese patients with PCI. Primary end points were incidence of first major adverse cardiac and cerebrovascular events (MACCE) and first major bleeding events at 12 months post-PCI. Platelet reactivity (P2Y12 reaction unit [PRU] value) was measured at 12 to 48 hours post-PCI; patients were grouped as having high PRU (>208), optimal PRU (>85 to ≤208), and low PRU (≤85). MACCE and major bleeding occurred in 4.4% and 2.8% of 6267 patients, respectively. The mean±SD PRU value was 182.1±77.1. MACCE was significantly higher in the high PRU (5.7%; n=2227) versus the optimal PRU group (3.6%; n=3002). The hazard ratio (HR) for high PRU versus optimal PRU level was significantly higher for MACCE (adjusted HR, 1.53; 95% CI, 1.14-2.06 [P=0.004]); stent thrombosis followed the same trend. Incidence of major bleeding did not differ significantly between groups. A high PRU level was significantly associated with MACCE in both patients with and patients without acute coronary syndrome. Conclusions These real-world data suggest an association between high platelet reactivity and cardiovascular events in Japanese patients undergoing PCI. The trend was the same in both patients with and patients without acute coronary syndrome. REGISTRATION URL: https://www.umin.ac.jp/ctr. Unique identifier: UMIN 000020332.

Control of collagen molecular assembly with anionic polysaccharides.

The effect of adding a polyanionic saccharide (alginic acid, pectic acid, agarose, kappa-carragenan or lambda-carragenan) to a collagen solution on the reconstruction rate of collagen molecular assembly was evaluated. The rate of collagen molecular assembly was reduced by the addition of alginic acid and of pectic acid that was containing carboxy groups. Dextran, agarose, and soluble starch did not affect the rate, while dextran sulfate and lambda-carragenan accelerated the rate of collagen molecular assembly. The denaturation curves of collagen reconstructed with lambda-carragenan showed two peaks at about 45 degrees C and 55 degrees C. The use of a polyanionic saccharide made it possible to endow the reconstructed collagen fibrils with flexibility to enhance the application of collagen as a scaffold material for tissue engineering.

Combined Direct Endarterectomy and Fogarty Thrombectomy with Endovascular Therapy for Subacute Occlusion of the Superficial Femoral Artery.

A 78-year-old woman with a prior history of a right femoropopliteal bypass 5 years before and a coronary artery bypass graft 3 months before was admitted for a non-healing ulcer on her right foot. A computed tomography angiogram revealed occlusion of her superficial femoral artery (SFA) from its orifice to the anastomotic site of the bypass graft. The lesion was thought to consist of a partial atherosclerotic plaque with a large number of relatively fresh thrombi, referring to an angiogram of her lower extremity 3 months ago. We recanalized the occlusive SFA by Fogarty thrombectomy, and endovascular therapy preceded by direct SFA endarterectomy.

Applicability of quantitative flow ratio for rapid evaluation of intermediate coronary stenosis: comparison with instantaneous wave-free ratio in clinical practice.

Quantitative flow ratio (QFR) is an image-based fractional flow reserve (FFR) computed by three-dimensional quantitative coronary angiography and estimated flow velocity. Several studies have reported that QFR was rapidly computed within approximately 5 min and had a good diagnostic performance as compared with FFR. However, studies comparing QFR with instantaneous wave-free ratio (iFR) as an index with a prognostic value comparable to that of FFR are limited. Thus, we investigated the applicability of QFR with respect to iFR, both being easy-to-measure indices not requiring pharmacological hyperaemic induction. We computed QFR in prospectively enrolled 150 coronary lesions (including 50 lesions for onsite QFR analysis) in consecutive patients with intermediate stenosis evaluated by iFR. The correlation and diagnostic performance of QFR were compared using iFR as a reference. The mean QFR and iFR were 0.81 ± 0.12 and 0.89 ± 0.11, respectively. QFR and iFR exhibited a good correlation in all subjects (R = 0.70, p < 0.0001) and the onsite-analysed vessels (R = 0.74, p < 0.0001). In the receiver-operating characteristics analysis, the area under the curve of QFR predicting iFR ≤ 0.89 was 0.91. Applying the cut-off value of QFR ≤ 0.80 and iFR ≤ 0.89, the sensitivity, specificity, positive and negative predictive values were 85%, 83%, 72%, and 91%, respectively, in all subjects, and 82%, 82%, 78%, and 85%, respectively, in the onsite-analysed vessels. QFR including onsite analysis demonstrated a good correlation with iFR and a diagnostic performance comparable to that of iFR in consecutive patients with intermediate coronary stenosis, suggesting its potential as a rapidly derived index for evaluating myocardial ischaemia in clinical settings.

Polyunsaturated Fatty Acid Impact on Clinical Outcomes in Acute Coronary Syndrome Patients With Dyslipidemia: Subanalysis of HIJ-PROPER.

Background This study aimed to examine the impact of baseline eicosapentaenoic acid (EPA) to arachidonic acid (AA) ratio on clinical outcomes of patients with acute coronary syndrome. Methods and Results In the HIJ-PROPER (Heart Institute of Japan Proper Level of Lipid Lowering With Pitavastatin and Ezetimibe in Acute Coronary Syndrome) study, 1734 patients with acute coronary syndrome and dyslipidemia were randomly assigned to pitavastatin+ezetimibe therapy or pitavastatin monotherapy. We divided the patients into 2 groups based on EPA/AA ratio on admission (cutoff 0.34 µg/mL as median of baseline EPA/AA ratio) and examined their clinical outcomes. The primary end point comprised all-cause death, nonfatal myocardial infarction, nonfatal stroke, unstable angina pectoris, or ischemia-driven revascularization. Percentage reduction of low-density lipoprotein cholesterol and triglyceride from baseline to follow-up was similar regardless of baseline EPA/AA ratio. Despite the mean low-density lipoprotein cholesterol level during follow-up being similar between the low- and high-EPA/AA groups, the mean triglyceride levels during follow-up were significantly higher in the low- than in the high-EPA/AA group. After 3 years of follow-up, the cumulative incidence of the primary end point in patients with low EPA/AA was 27.2% in the pitavastatin+ezetimibe group compared with 36.6% in the pitavastatin-monotherapy group (hazard ratio 0.69; 95% CI, 0.52-0.93; P=0.015). However, there was no effect of pitavastatin+ezetimibe therapy on the primary end point in patients with high EPA/AA (hazard ratio 0.92; 95% CI, 0.70-1.20; P=0.52). Conclusions Among acute coronary syndrome patients who have dyslipidemia and low EPA/AA ratio, adding ezetimibe to statin decreases the risk of cardiovascular events compared with statin monotherapy. Clinical Trial Registration URL: http://www.umin.ac.jp/ctr. Unique identifier: UMIN000002742.

Clinical Factors Relevant to the Recurrence of Atrial Tachyarrhythmia after Extensive Defragmentation Followed by Thoracic Vein Isolation.

INTRODUCTION: The efficacy of thoracic vein isolation (TVI), an approach to trigger atrial fibrillation (AF), for the management of AF has been established. Our goal was to identify the predictors for late recurrence of atrial tachyarrhythmias (ATAs), for which the patients and procedural and/or echocardiographic parameters were retrospectively analyzed. Although substrate modification in the atrium for the treatment of AF ablation remains controversial, the background associated with the outcome has not been fully investigated. We retrospectively studied 33 patients with paroxysmal AF and 21 with persistent AF undergoing defragmentation followed by TVI. We evaluated the late/early recurrences, defined as ATA at 3 months after/within the single procedure. METHODS AND RESULTS: During a median follow-up period of 22 (11-37) months, 28 patients (52%) experienced a late recurrence. There was a higher incidence of late recurrences in the patients with disease durations of ≥12.4 months, which was the optimal cut-off point measured in the receiver operating characteristic curve analysis, or in those with left atrial diameter >50 mm or with earlier recurrences than the others (19% versus 72%, p=0.01; 0% versus 37%, p=0.02; or 13% versus 53%, p<0.0001 by the log-rank test, respectively). Moreover, there was a trend toward a higher atrial tachycardia (AT)-free rate in the patients with AF termination during the procedure (75% versus 54%, p=0.07 by the log-rank test). A multivariate analysis based on the Cox proportional hazard model showed that disease duration ≥12.4 months or early recurrence was highly associated with the outcomes (HR 3.72, 95%CI 1.42-12.79, p<0.006; HR 4.80, 95%CI 2.24-10.56, p<0.0001). CONCLUSION: The AF duration and early ATA recurrence are the peri-procedural factors significantly relevant to the outcome after extensive defragmentation followed by TVI.

Successful elimination of premature ventricular contractions by ablation of origin and preferential pathway.

However, the common strategy for eliminating premature ventricular contractions (PVCs) is to explore the exit site and ablate, which may be difficult in some cases. The origin and the preferential pathway, an insulated pathway connected to the exit, may also become targets for eliminating PVCs.

Interesting electrophysiological findings in a patient with coexistence of atrial tachycardia originating from coronary sinus and slow-fast atrioventricular nodal reentrant tachycardia.

Slow-fast atrioventricular nodal tachycardia (AVNRT) has various electrophysiological aspects due to atrioventricular (AV) nodal physiology. In addition, concomitantly another form of arrhythmia with AVNRT, especially atrial tachycardia (AT), was an infrequent arrhythmia. A 38-year-old female with narrow QRS tachycardia underwent electrophysiological study due to frequent faintness. The electrophysiological study disclosed the coexistence of AT originating from coronary sinus (CS) with slow-fast AVNRT. We easily diagnosed AT originating from CS and terminated with several radiofrequency ablations (RFA) around CS. The diagnosis of slow-fast AVNRT, however, was somewhat difficult due to the following findings: (1) small amount of adenosine triphosphate (ATP) could terminate slow-fast AVNRT reproducibly; (2) we could provoke slow-fast AVNRT only by RV pacing with isoproterenol infusion. With other electrophysiological findings, we diagnosed slow-fast AVNRT. Radiofrequency energy was delivered initially in the posteroseptal region, followed by inside CS, and finally in the middle septal region, which completed the slow pathway ablation. After the procedure, we could never provoke these arrhythmias. .