Electrophysiologic approach to diagnosis and ablation of patients with permanent junctional reciprocating tachycardia associated with complex anatomy and/or physiology

Abstract

Introduction: Permanent junctional reciprocating tachycardia (PJRT) is a rare supraventricular tachycardia (SVT), typically involving a single decremental posteroseptal accessory pathway (AP). Methods: Four patients with long RP SVT underwent electrophysiology (EP) study and ablation. The cases were reviewed. Results: Case 1 recurred despite 3 prior ablations at the site of earliest retrograde atrial activation during orthodromic reciprocating tachycardia (ORT). Mapping during a repeat EP study demonstrated a prepotential in the coronary sinus (CS). Ablation over the earliest atrial activation in the CS resulted in dissociation of the potential from the atrium during sinus rhythm. The potential was traced back to the CS os and ablated. Case 2 underwent successful ablation at 6 o'clock on the mitral annulus (MA). ORT recurred and successful ablation was performed at 1 o'clock on the MA. Case 3 had tachycardia with variation in both V-A and A-H intervals which precluded the use of usual maneuvers so we used simultaneous atrial and ventricular pacing and introduced a premature atrial contraction with a closely coupled premature ventricular contraction. Case 4 had had two prior atrial fibrillation ablations with continued SVT over a decremental atrioventricular bypass tract that was successfully ablated at 5 o'clock on the tricuspid annulus. A second SVT consistent with a concealed nodoventricular pathway was successfully ablated at the right inferior extension of the AV nodal slow pathway.

Novel Approaches for the Diagnosis of Concealed Nodo-Ventricular and His-Ventricular Pathways

“…[3][4][5] Previous studies emphasized the importance of ventricular stimulation during tachycardias such as His refractory PVCs and VOD pacing to determine ventricular fusion, PPI-TCL and SA-VA measurements, as well as recording orthodromic His and right bundle activation sequence during entrainment. [1][2][3][4][5][6][7][8][9][10] In this series, we described 7 cases of cNV or cHV pathway-mediated arrhythmias and focused on several novel observations in response to ventricular pacing. Moreover, we studied the important roles of paradoxical atriohisian response in long RP tachycardia as well as use of adenosine in distinguishing cNV versus cHV pathways.…”

“…Concealed nodo-ventricular (cNV) or concealed His-ventricular (cHV) pathways are rare accessory pathway (AP) variants that may be involved in the mechanism of reentrant supraventricular tachyarrhythmias (SVTs). 1–10 These arrhythmias represent important challenges for the clinician to separate from the more common arrhythmia mechanisms. Hence, the introduction of newer approaches to raise suspicion of the presence of these pathways as well as proof that these pathways are a critical part of the reentrant circuit is always important.…”

Clinical Course and Electrophysiological Characteristics of Permanent Junctional Reciprocating Tachycardia in Children

“…Although PJRT can be found at any age, beginning in the fetal period, the majority of research and case reports in the children's age range are under the age of 1 year. 8 - 11 However, there have been studies conducted on adults. The mean age in our study was found to be greater than in other pediatric age group studies.…”

Neonatal supraventricular tachyarrhythmias, approach and treatment from pathophysiology

“…It is a type of arrhythmia that occurs due to an uncommon reentrant mechanism and, in most cases, a decreasing posteroseptal accessory pathway with low conduction velocity does participate 45 . Characteristically, it is incessant, and electrocardiographic features are those of a tachycardia with regular, narrow QRS complexes, with a very long RP interval and a normal PR interval, but with an abnormal P wave axis, unlike in sinus rhythm.…”