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Pacing and Clinical Electrophysiology :... Aug 2023Open-window mapping (OWM) is a novel automated mapping method for catheter ablation of an accessory pathway (AP), in which the local signal is annotated with...
BACKGROUND
Open-window mapping (OWM) is a novel automated mapping method for catheter ablation of an accessory pathway (AP), in which the local signal is annotated with window-of-interest parameters to analyze both atrial and ventricular signals. This study aimed to determine the utility of OWM in visualizing the location and width of APs in patients with Wolff-Parkinson-White syndrome.
METHODS
This two-center study enrolled 30 patients (20 males; mean age: 56 years, interquartile range [IQR]: 22-69 years) who underwent high-density OWM with the extended early-meets-late (EEML) algorithm using a 20-electrode, 5-spline catheter (PENTARAY, Biosense Webster). The lower threshold of the EEML was set to adjust the EEML gap to match the propagation mapping, and broad APs were defined as an EEML gap > 1 cm.
RESULTS
The median mapping points, mapping time, and lower threshold of the EEML were 2482 (IQR: 1755-4000) points, 23 (IQR: 15-30) min, and 23 (IQR: 18-25), respectively. All 30 APs (24 in the mitral annulus and 6 in the tricuspid annulus) were successfully eliminated. Of these APs, 21 (70%) were eliminated by the first radio frequency (RF) application. OWM revealed broad APs in 11 patients (37%), in four of whom (36%) the first RF application achieved a loss of AP conduction (vs. 90% of patients without broad APs; p = .004).
CONCLUSION
OWM facilitates the visualization of the location and width of APs, which may be particularly useful for predicting whether multiple RF applications are required for broad APs.
Topics: Male; Humans; Young Adult; Adult; Middle Aged; Aged; Wolff-Parkinson-White Syndrome; Accessory Atrioventricular Bundle; Catheter Ablation; Heart Ventricles; Radio Waves; Electrocardiography
PubMed: 37493225
DOI: 10.1111/pace.14795 -
Pacing and Clinical Electrophysiology :... Sep 2023Intermittent ventricular pre-excitation was considered a low-risk marker for sudden death. However, to date, some studies do not exclude the existence of accessory...
BACKGROUND
Intermittent ventricular pre-excitation was considered a low-risk marker for sudden death. However, to date, some studies do not exclude the existence of accessory pathways (APs) with high-risk intermittent antegrade conductive properties. According to current European Guidelines, high-risk features of APs are antegrade pathway conduction ≤250 ms in baseline or during the adrenergic stimulus, inducibility of atrioventricular reciprocating tachycardias (AVRT), inducibility of pre-excited atrial fibrillation (AF), and presence of multiple APs. For all of these transcatheter ablation is recommended. The aim of our study was to evaluate the existence of differences in risk characteristics between patients with intermittent pre-excitation (IPX) and those with persistent pre-excitation (PPX), from a sample of adults with ventricular pre-excitation and symptoms like palpitations.
METHODS
293 adults [IPX: 51 (17.4%); PPX: 242 (82.6%)] underwent electrophysiological study and then catheter ablation of their APs if arrhythmia inducibility (AVRT/AF) was noted, or, conversely, if it was appreciated a fast AP antegrade conduction, in baseline or during intravenous isoproterenol infusion, or if multiple APs were detected.
RESULTS
There were no statistically significant differences in demographic characteristics (age and gender), AVRT/AF inducibility, antegrade conductive properties, the prevalence of multiple APs, and APs locations between IPX and PPX patients.
CONCLUSIONS
In our study, patients with IPX did not show significant differences in clinical and electrophysiological features versus PPX patients.
Topics: Humans; Adult; Wolff-Parkinson-White Syndrome; Pre-Excitation Syndromes; Accessory Atrioventricular Bundle; Atrial Fibrillation; Risk Factors; Catheter Ablation; Electrocardiography
PubMed: 37527153
DOI: 10.1111/pace.14798 -
Europace : European Pacing,... Feb 2024Controversy remains as to whether the exercise stress test (EST) is sufficient for risk evaluation in patients with pre-excitation. This study aims to clarify the...
AIMS
Controversy remains as to whether the exercise stress test (EST) is sufficient for risk evaluation in patients with pre-excitation. This study aims to clarify the usefulness of EST in risk stratification in both asymptomatic and symptomatic patients presenting with pre-excitation.
METHODS AND RESULTS
This prospective study includes consecutive asymptomatic and symptomatic patients with pre-excitation referred for risk assessment. All participants performed an incremental EST (bicycle) prior to an electrophysiology study (EPS). Primary data from the EST included loss of pre-excitation during exercise, and primary data from the EPS included the measurement of accessory pathway effective refractory period (APERP), shortest pre-excited RR interval (SPERRI), and inducible arrhythmia with the use of a beta-adrenergic receptor agonist if deemed necessary. One hundred and sixty-four patients (59 asymptomatic, 105 symptomatic) completed an EST and EPS. Forty-five patients (27%) demonstrated low-risk findings on EST, of which 19 were asymptomatic and 26 were symptomatic. Six patients with low-risk EST findings had SPERRI/APERP ≤ 250 ms at EPS, and two of them were asymptomatic. The sensitivity, specificity, positive predictive value, negative predictive value (NPV), and accuracy of low-risk EST for excluding patients with SPERRI/APERP ≤ 250 ms were 40, 91, 87, 51, and 60%, respectively. The number of patients with inducible arrhythmia at EPS was similar in the asymptomatic (36, 69%) and symptomatic (73, 61%) groups.
CONCLUSION
Sudden loss of pre-excitation during EST has a low NPV in excluding high-risk APs. The EPS with the use of isoproterenol should be considered to accurately assess the risk of patients with pre-excitation regardless of symptoms (ClinicalTrials.gov Identifier: NCT03301935).
Topics: Humans; Wolff-Parkinson-White Syndrome; Prospective Studies; Pre-Excitation Syndromes; Accessory Atrioventricular Bundle; Risk Assessment; Electrocardiography
PubMed: 38363996
DOI: 10.1093/europace/euae036 -
Clinical Case Reports Nov 2023Atrial flutter (AFL) and supraventricular tachycardia (SVT) are common arrhythmias in clinic. However, some AFL cases may present additional complexities, such as both...
Wide QRS complex tachycardia with a mysterious mask-Tricuspid isthmus-dependent atrial flutter with preexcitation syndrome and dual atrioventricular nodal pathway conduction.
KEY CLINICAL MESSAGE
Atrial flutter (AFL) and supraventricular tachycardia (SVT) are common arrhythmias in clinic. However, some AFL cases may present additional complexities, such as both accessory pathways (AP) and dual atrioventricular node pathways, putting on a mysterious mask and making it challenging to distinguish on electrocardiograms (ECGs).
ABSTRACT
A 60-year-old male patient had a sudden syncope, and an ECG showed wide QRS complex tachycardia. This diagnostic ambiguity is further compounded by the fact that SVT via AP conduction can exhibit wide QRS complex tachycardia characteristics resembling ventricular tachycardia (VT). Consequently, a definitive diagnosis through electrophysiological (EP) examination becomes imperative, as it dictates subsequent ablation strategies. In this article, we present a rare case involving three distinct arrhythmias including AFL, AP, and dual atrioventricular node pathways, and successfully treated through ablation.
PubMed: 38028054
DOI: 10.1002/ccr3.8202 -
Journal of Cardiovascular... Sep 2023Accessory atrioventricular pathways (APs) may mediate atrioventricular reciprocating tachycardia and, in some cases, have the potential to conduct atrial tachycardia...
INTRODUCTION
Accessory atrioventricular pathways (APs) may mediate atrioventricular reciprocating tachycardia and, in some cases, have the potential to conduct atrial tachycardia rapidly, which can be life threatening. While catheter ablation can be curative, ablation of right free wall APs is associated with a high rate of recurrence, likely secondary to reduced catheter stability along the right free wall atrioventricular groove. We sought to identify characteristics associated with a lower rate of recurrence and hypothesized ablation lesions placed on the ventricular side of the atrioventricular groove using a retroflexed catheter approach would decrease rates of recurrence.
METHODS AND RESULTS
Retrospective chart review of patients who underwent catheter ablation of a right free wall AP from January 1, 2008 through June 1, 2021 with >2 months follow up. Cox proportional hazards regression was used to identify relationships between predictor variables and AP recurrence. We identified 95 patients who underwent ablation of 98 right free wall APs. Median age was 13.1 years and median weight at ablation was 52.3 kg. Overall, 23/98 (23%) APs recurred. Use of a retroflexed catheter course approaching the atrioventricular groove from the ventricular aspect was associated with reduced risk of AP recurrence with (univariable hazard ratio of 0.10 [95% confidence interval: 0.01-0.78]), which remained significant in multiple two variable Cox proportional hazards models.
CONCLUSION
Use of a retroflexed catheter course is associated with a reduced likelihood of AP recurrence. This approach results in improved catheter stability and should be considered for ablation of right free wall APs.
Topics: Humans; Adolescent; Wolff-Parkinson-White Syndrome; Retrospective Studies; Bundle of His; Accessory Atrioventricular Bundle; Ventricular Septum; Catheters; Catheter Ablation
PubMed: 37449445
DOI: 10.1111/jce.16003 -
Herzschrittmachertherapie &... Mar 2024The history of surgical treatment of ventricular tachycardias (VT) is short, lasting from 1978 until 1993. "Indirect procedures" with infarct scar resection were... (Review)
Review
[History of surgical treatment of cardiac arrhythmias in Germany : Surgical treatment of ventricular tachycardia and supraventricular tachycardia, especially pre-excitation syndromes (WPW)].
The history of surgical treatment of ventricular tachycardias (VT) is short, lasting from 1978 until 1993. "Indirect procedures" with infarct scar resection were performed without electrophysiologic studies, whereas "direct procedures" consisted of either complete endocardial incisions ("encircling endocardial ventriculotomy") or large endocardial resections ("endocardial peel-off" technique) after precise epicardial and endocardial mapping procedures. In Germany, the first to report on intra-operative electrophysiologic mapping for VT treatment were Ostermeyer, Breithardt and Seipel in 1979. In 1981, the Hannover group (Frank, Klein) published their first results of surgical treatment of VT. In 1984, Ostermeyer et al. demonstrated that a partial endocardial incision resulted in more beneficial results with less myocardial damage (8% versus 46%) than applying a complete encircling incision. In 1987, the Düsseldorf group reported treatment results of 93 patients. After 5 years, 77% had no VT recurrence, while total mortality after 1 year was 11% and after 5 years 30%. In 1992, the Hannover group reported results of 147 patients after endocardial resection for VT. Total mortality after 3 years was 27%; recurrence of VT events occurred in 18% of the surviving cohort.The history of surgical procedures for supraventricular tachycardia (SVT), in particular Wolff-Parkinson-White (WPW) syndrome, is even shorter than that of surgery for VT. As early as 1969, Sealy, Gallagher and Cox reported the first cases of surgical intervention for WPW syndrome via endocardial access in cardioplegic arrest. In 1984, Guiraudon and Klein reported on a new procedure with epicardial access to the accessory bundle without cardioplegia in laterally localised conduction pathways. In Germany, too, the groups in Düsseldorf (Ostermeyer, Seipel, Breithardt, Borggrefe) from 1980 and the Hannover group (Frank, Klein and Kallfelz) from 1981 performed surgical procedures for WPW syndrome. In 1987, Borggrefe reported on 18 patients with WPW syndrome and atrial fibrillation who had undergone surgery. After 2 years, 14 of 18 patients had no recurrences of tachycardia; in 1989, Frank, Klein and Kallfelz (Hannover) reported on 10 children (2-14 years) operated on using the cryoablation technique. Between 1984 and 1992, a total of 120 patients with SVT, mostly WPW syndrome, were operated on in Hannover; after 42 months, 12 patients had a recurrence of SVT. Two patients died during the reoperation.
Topics: Child; Humans; Wolff-Parkinson-White Syndrome; Tachycardia, Supraventricular; Tachycardia, Ventricular; Pre-Excitation Syndromes; Atrial Fibrillation
PubMed: 38416160
DOI: 10.1007/s00399-024-01012-2 -
Cardiology in the Young Aug 2023Twelve-lead ECG of a child with Wolff-Parkinson-White syndrome and systolic dysfunction was consistent with the anteroseptal accessory pathway. The earliest atrial...
Twelve-lead ECG of a child with Wolff-Parkinson-White syndrome and systolic dysfunction was consistent with the anteroseptal accessory pathway. The earliest atrial activation during electrophysiological study was found between the right anteroseptal region near the HIS. Multiple femoral tract right-sided cryotest lesions followed by radiofrequency catheter irrigated through the jugular vein route were unsuccessful. Then, non-coronary aortic cusp mapping and cryoablation were successfully performed with a retroartic approach.
Topics: Humans; Child; Wolff-Parkinson-White Syndrome; Heart Atria; Electrocardiography; Aorta; Catheter Ablation
PubMed: 36660903
DOI: 10.1017/S1047951123000045 -
Journal of Interventional Cardiac... Aug 2023Sudden cardiac death (SCD) may rarely occur among asymptomatic patients with Wolff-Parkinson-White (WPW) pattern. Risk stratification is based on electrophysiological...
BACKGROUND
Sudden cardiac death (SCD) may rarely occur among asymptomatic patients with Wolff-Parkinson-White (WPW) pattern. Risk stratification is based on electrophysiological study (EPS). We aimed to evaluate long-term efficacy of such a strategy in preventing SCD.
METHODS
Retrospective analysis of asymptomatic children with WPW who underwent EPS using isoproterenol. Patients considered at risk had inducible sustained atrial fibrillation or atrioventricular reentry tachycardia (AVRT) associated with the following: (1) accessory pathway (AP) effective refractory period or (2) 1:1 shortest cycle length along the AP or (3) shortest pre-excited R-R interval during AF ≤ 250 ms.
RESULTS
Fifty-one consecutive cases (7-18 years, 12 ± 3) were identified, 40 (78%) with right and 11 (22%) with left AP. Twenty-eight (55%) were classified as high risk (HI) and 23 (45%) as low risk (LO), with no significant differences in demographic characteristics and AP locations. Ablation was performed in 20/28 HI and 11/23 LO patients (p 0.08), with no significant differences in acute success (20/20 versus 10/11, p 0.17) or recurrence (1/20 versus 2/10, p 0.15). Follow-up (46 ± 27 months): ablated patients remained asymptomatic; among the 23 non-ablated, 18 (78%) remained asymptomatic, 5 (22%) were successfully ablated, and 5 (22%) presented events (4 AVRT, 1 SCD). Arrhythmic events did not differ significantly between non-ablated HR and LR (2/8 versus 3/15, p 0.29) and the SCD was in the LO group.
CONCLUSIONS
More than 50% asymptomatic WPW children present high-risk AP properties. EPS-based risk stratification using isoproterenol was not able to identify increased risk of future events or SCD.
Topics: Humans; Child; Wolff-Parkinson-White Syndrome; Retrospective Studies; Accessory Atrioventricular Bundle; Death, Sudden, Cardiac; Atrial Fibrillation; Tachycardia, Supraventricular; Isoproterenol; Catheter Ablation; Electrocardiography
PubMed: 36394700
DOI: 10.1007/s10840-022-01409-4 -
Pacing and Clinical Electrophysiology :... Nov 2023We describe two patients with right supero-paraseptal accessory pathway (SPAP) who developed left ventricular dysfunction associated with an increased degree of...
INTRODUCTION
We describe two patients with right supero-paraseptal accessory pathway (SPAP) who developed left ventricular dysfunction associated with an increased degree of ventricular pre-excitation and frequent orthodromic reciprocating tachycardia (ORT) due to worsening atrioventricular (AV) node conduction.
METHODS AND RESULTS
Case 1: 48-year-old female with a history of normally functioning mechanical mitral valve, CABG, and ventricular pre-excitation that worsened after her open heart surgery. She presented with frequent palpitations with documented supraventricular tachycardia (SVT) and found to have a new left ventricular dysfunction with decrease in left ventricular ejection fraction (LVEF) from 55% to 46% with dyssynchrony. An electrophysiological study confirmed a right SPAP and ORT. The pathway was successfully ablated from the antegrade approach after careful mapping. After ablation and 6-month follow up echocardiogram showed improvement of EF to 54% and the LV dyssynchrony resolved. Case 2: 51-year-old male with a history of frequent SVT with recent unsuccessful ablations that resulted in worsening ventricular pre-excitation, more frequent SVT, and new left ventricular dysfunction (LVEF from 60% to 40%). He was started on amiodarone which resulted in significant sinus bradycardia, intermittent ventricular pre-excitation, and first degree AV block with significant increase in ORT events. His electrophysiology study confirmed SPAP which was successfully ablated from the antegrade approach after careful mapping. After 1 month, follow-up echocardiogram showed an improved ejection fraction to 60%.
CONCLUSION
Left ventricular dysfunction due to dyssynchrony and symptomatic frequent ORT of right SPAP can develop in the setting of new iatrogenic diminished AV node conduction. Successful ablation will result in LV function recovery to baseline.
Topics: Humans; Male; Female; Middle Aged; Stroke Volume; Electrocardiography; Ventricular Function, Left; Accessory Atrioventricular Bundle; Tachycardia, Supraventricular; Tachycardia, Paroxysmal; Tachycardia, Reciprocating; Ventricular Dysfunction, Left; Pre-Excitation Syndromes; Cardiomyopathies; Iatrogenic Disease; Catheter Ablation
PubMed: 36851895
DOI: 10.1111/pace.14684 -
Journal of Electrocardiology 2024Accurate estimation of accessory pathway (AP) localization in patients with ventricular pre-excitation or Wolff-Parkinson-White (WPW) syndrome remains a diagnostic...
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.
Topics: Humans; Algorithms; Accessory Atrioventricular Bundle; Male; Female; Wolff-Parkinson-White Syndrome; Sensitivity and Specificity; Retrospective Studies; Electrocardiography; Adult; Catheter Ablation; Reproducibility of Results; Pre-Excitation Syndromes; Middle Aged
PubMed: 38430664
DOI: 10.1016/j.jelectrocard.2024.02.007