Atrial Tachycardia Originating in the Vicinity of the Noncoronary Sinus of Valsalva: Report of a Series Including the First Case of Ablation‐Related Complete Atrioventricular Block

Barkagan, Michael; Michowitz, Yoav; Glick, Aharon; Tovia-Brodie, Oholi; Rosso, Raphaël; Belhassen, Bernard

doi:10.1111/pace.12941

Cited by 12 publications

(10 citation statements)

References 11 publications

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“…Spector et al conducted a meta‐analysis of the RF ablation outcome of SVTs and reported that the percentage of patients with AVB was 1.7% for AVNRT and 0.8% for APs, and the need for a pacemaker was 0.7% for AVNRT and 0.3% for APs (all AP locations were included). Barkagan et al assessed the outcome of RF ablation in nine patients with an AT originating from the vicinity of the noncoronary sinus of Valsalva and reported that a successful RF ablation of the AT was associated with complete AVB requiring an implantation of a permanent pacemaker in one patient.…”

Section: Discussionsupporting

confidence: 88%

Outcome of combined cryo‐ and radiofrequency‐catheter ablation in patients with supraventricular tachycardias

Miyamoto

Kapa

Mulpuru

et al. 2019

Cardiovasc electrophysiol

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Background There are few data regarding the outcome of a combined cryo‐ and radiofrequency (RF)‐catheter ablation of various types of supraventricular tachycardias (SVTs) originating from near the normal conduction system. METHODS We analyzed all patients undergoing combined cryo‐ and RF‐ catheter ablation at Mayo Clinic, Rochester, MN as part of the ablation of SVTs with potential risks of injury to the normal conduction system. This study aimed to assess the outcome of a combined cryo‐ and RF‐catheter ablation of various types of SVTs. RESULTS The study population consisted of 54 patients (38 ± 17 years, 32 men). A combined cryo‐ and RF‐catheter ablation was attempted for septal accessary pathways (APs) in 26, atrioventricular nodal reentrant tachycardia (AVNRT) in 14, atrial tachycardia (AT) in 7, and junctional ectopic tachycardia in 7 patients. Forty‐one patients (76%) were successfully ablated with cryoablation, and RF ablation after an unsuccessful cryoablation ablated the SVTs successfully at the same location in 6 patients (11%). Complication occurred in 1 patient (deep vein thrombosis). The cumulative freedom from SVT rate at 30 days after the procedure was 78% and there was no significant difference in the recurrence rate among the SVTs. CONCLUSION A combined cryo‐ and RF‐catheter ablation is clinically effective in patients undergoing SVT ablation with the potential risk of injury to the normal conduction system.

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Section: Discussionsupporting

confidence: 88%

Outcome of combined cryo‐ and radiofrequency‐catheter ablation in patients with supraventricular tachycardias

Miyamoto

Kapa

Mulpuru

et al. 2019

Cardiovasc electrophysiol

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“…Recently, the complication of complete atrioventricular block was reported by NCC-A. 15 On the contrary, 48 of the 55 patients with para-Hisian APs in our study were successfully ablated by IVC-A with lower On the basis of the results of the present study, a new catheter ablation strategy for para-Hisian APs can be delineated. If a para-Hisian AP is identified, the degree of fusion between the ventricular and the atrial potentials during retrograde AP conduction should be assessed.…”

Section: Catheter Ablation Strategy For Para-hisian Apsmentioning

confidence: 75%

Different Approaches for Catheter Ablation of Para-Hisian Accessory Pathways

Liang

Wang

Yang

et al. 2017

Circ: Arrhythmia and Electrophysiology

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Background-Catheter ablation of para-Hisian accessory pathways (APs) can be challenging because of adjacent conduction tissue. Some different approaches for ablation, including the inferior vena cava approach (IVC-A), the noncoronary cusp approach (NCC-A), or the superior vena cava approach (SVC-A), have been reported. However, when should para-Hisian APs be mapped and ablated by the IVC-A, NCC-A, or SVC-A is not well established. Methods and Results-This study included 55 consecutive patients (mean age, 53±11 years, 36 males) with para-Hisian APs. On the basis of the approach resulting in successful ablation, patients were divided into IVC-A, NCC-A, and SVC-A groups. The clinical characteristics, surface ECG, intracardiac electrogram findings, and response to ablation were analyzed. Para-Hisian APs were eliminated by IVC-A in 48 of the 55 (87%) patients. The rates of para-Hisian APs requiring NCC-A (4/55 patients, 7%) and SVC-A (3/55 patients, 6%) were relatively low. During mapping at the paraHisian region, the local ventricular and atrial potentials were well fused during retrograde AP conduction in 45 of the 48 patients in IVC-A group, 0 of the 4 patients in NCC-A group, and 1 of the 3 patients in SVC-A group, respectively. There was no significant difference in the preexcitation characteristics among the 3 groups. Conclusion-Most para-Hisian APs can be safely and effectively ablated by IVC-A, and ablation in the NCC is not an initial or a preferred approach. The degree of local ventriculoatrial fusion in the para-Hisian region during retrograde AP conduction can differentiate or predict the successful ablation site. (Circ Arrhythm Electrophysiol. 2017;10:e004882.

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“…Evaluation of the P wave during periods of AV block (Figure , arrow) reveal a biphasic morphology in lead aVF (negative/positive) incompatible with typical AVNRT and characteristic of AT arising from the noncoronary cusp (NCC) of the aortic valve . In this case, NCC AT (causing earliest atrial activation at the His bundle region) in the presence of dual AV nodal physiology and sustained slow pathway (SP) conduction (causing simultaneous atrioventricular activation) mimics typical AVNRT . Repetitive retrograde concealment from SP into fast pathway (FP) perpetuates sustained SP conduction during ongoing AT.…”

Section: Discussionmentioning

confidence: 87%

Supraventricular tachycardia with VA Linking: What is the mechanism?

Logue

2019

Cardiovasc electrophysiol

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A 72-year-old male with chronic right bundle branch block underwent diagnostic electrophysiologic study because of the recurrent symptomatic supraventricular tachycardia (SVT). Atrio-His and His-ventricular intervals measured 115 ms and 58 ms, respectively. Programmed atrial extrastimulation elicited dual atrio-ventricular (AV) node physiology; VA conduction was absent. A single atrial extrastimulus-induced SVT after an AH jump (Figure 1). Attempts to entrain tachycardia from the ventricle resulted in AV dissociation. The response to atrial overdrive pacing (AOP) from the high right atrium (HRA) and coronary sinus (CS) is shown in Figure 2. On the basis of the figures, what is the mechanism of tachycardia? DISCUSSION Supraventricular tachycardia shows midline atrial activation earliest at the His bundle region. Simultaneous atrioventricular activation and spontaneous periods of AV nodal Wenckebach block exclude orthodromic reciprocating tachycardia (ORT). Tachycardia induction after an AH jump, simultaneous atrioventricular activation, and earliest atrial activation at the His bundle suggest typical atrioventricular nodal reentrant tachycardia (AVNRT). Absent VA conduction with the inability to entrain tachycardia from the ventricle and persistence of tachycardia during AV block can be explained by retrograde and antegrade block in the lower common final pathway, respectively. Differential AOP from the HRA and CS produce "AHA" responses excluding junctional tachycardia and show VA linking (ΔVA = VA (CS) − VA (HRA) = 2ms) despite generating different AH intervals. VA linking indicates an AV nodal dependent tachycardia, and combined with the other aspects of this case favors AVNRT whereas seemingly excluding AT. 1,2 Despite these findings, however, the absence of VA conduction and the presence of AV nodal block are each individually uncommon during AVNRT and together raise suspicion for atrial tachycardia (AT). Evaluation of the P wave during periods of AV block (Figure 1, arrow) reveal a biphasic morphology in lead aVF (negative/positive) incompatible with typical AVNRT and characteristic of AT arising from the noncoronary cusp (NCC) of the aortic valve. 3,4 In this case, NCC AT (causing earliest atrial activation at the His bundle region) in the presence of dual AV nodal physiology and sustained slow pathway (SP) conduction (causing simultaneous atrioventricular activation) mimics typical AVNRT. 5 Repetitive retrograde concealment from SP into fast pathway (FP) perpetuates sustained SP conduction during ongoing AT. The apparent VA linking with differential AOP is best explained by SP conduction and the induction of typical (slow-fast) AV nodal echoes, which themselves (rather than atrial pacing per se) re-induce AT (particularly given the close proximity between the FP and NCC). With the diagnosis of NCC AT, the patient underwent successful ablation using a retrograde transaortic approach, but then easily developed sustained AVNRT manifesting multiple AV nodal pathways (Figure 3). In contrast to AT where the tran...

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Atrial Tachycardia Originating in the Vicinity of the Noncoronary Sinus of Valsalva: Report of a Series Including the First Case of Ablation‐Related Complete Atrioventricular Block

Abstract: Focal AT can be successfully mapped and ablated in the NCSV. Higher than usual RF energy levels are sometimes required. Complete AV block is a possible complication.

Cited by 12 publications

References 11 publications

Outcome of combined cryo‐ and radiofrequency‐catheter ablation in patients with supraventricular tachycardias

Outcome of combined cryo‐ and radiofrequency‐catheter ablation in patients with supraventricular tachycardias

Different Approaches for Catheter Ablation of Para-Hisian Accessory Pathways

Supraventricular tachycardia with VA Linking: What is the mechanism?

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