Entrainment Mapping of a Concealed Nodoventricular Accessory Pathway in a Man with Complete Heart Block and Tachycardia‐Induced Cardiomyopathy

Quinn, F. Russell; Mitchell, L. Brent; Mardell, Andrew; Disler, R.N. Dal; Veenhuyzen, George D.

doi:10.1111/j.1540-8167.2007.00916.x

Cited by 30 publications

(18 citation statements)

References 20 publications

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“…43 In this case, atrial extrastimuli fail to induce advancement of the following preexcited QRS complex, the next retrograde His bundle deflection where apparent, and the subsequent atrial deflection without changing the retrograde atrial activation sequence, as may happen in the presence of a macroreentrant loop ( Figure 6). Although no extensive series have been published, application of entrainment criteria (SA-VA and PPI-TCL) from the apex 44 or the apex and the base for differential entrainment 45 is theoretically appealing and has been proposed to distinguish between antidromic AVRT and AVNRT with a bystander fiber.…”

Section: Electrophysiology Studymentioning

confidence: 99%

Atrioventricular Nodal Reentrant Tachycardia

2010

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A trioventricular nodal reentrant tachycardia (AVNRT) represents the most common regular supraventricular arrhythmia in humans. 1 The precise anatomic site and nature of the pathways involved have not yet been established, and several attempts to provide a reasonable hypothesis based on anatomic or anisotropic models have been made. 2 There has been considerable evidence that the right and left inferior extensions of the human atrioventricular (AV) node and the atrionodal inputs they facilitate may provide the anatomic substrate of the slow pathway, and a comprehensive model of the tachycardia circuit for all forms of AVNRT based on the concept of atrionodal inputs has been proposed. 2 Still, however, the circuit of AVNRT remains elusive. Recently, time-honored conventional schemes for the diagnosis and classification of the various forms of the arrhythmia have been refuted in part by evolving evidence. Recognition of the various types of AVNRT is important, however, to expedite diagnosis and allow implementation of appropriate ablation therapy without complications. We present an update on AVNRT with a particular emphasis on electrophysiological criteria used for the differential diagnosis of regular, supraventricular tachycardias. ECG PresentationTypically, AVNRT is a narrow-complex tachycardia, ie, QRS duration Ͻ120 ms, unless aberrant conduction, which is usually of the right bundle-branch type, or a previous conduction defect exists. Tachycardia-related ST depression and RR-interval variation may be seen. RR alternans in AVNRT has been attributed to the proposed model of a figure of 8 reentry with continuous crossing over of antegrade activation through an inferior input to the contralateral superior input via the node. 2 In the typical form of AVNRT (slow-fast), abnormal (retrograde) PЈ waves are constantly related to the QRS and in the majority of cases are indiscernible or very close to the QRS complex (RPЈ/RR Ͻ0.5). Thus, PЈ waves are either masked by the QRS complex or seen as a small terminal PЈ wave that is not present during sinus rhythm (Figure 1). In the atypical form of AVNRT (fast-slow), PЈ waves are clearly visible before the QRS, ie, RPЈ/PЈR Ͼ0.75 (Figure 2), denoting a "long RP tachycardia," and are negative in leads II, III, aVF, and V 6 but positive in V 1 . PЈ waves are shallow in the inferior leads in the rare form of anterior fast-slow AVNRT. 3 Although AV dissociation is usually not seen, it can occur because neither the atria or the ventricles are necessary for the reentry circuit. If the tachycardia is initiated by atrial ectopic beats, the initial (ectopic) PЈ wave usually differs from the subsequent (retrograde) PЈ waves (Figure 1).

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Section: Electrophysiology Studymentioning

confidence: 99%

Atrioventricular Nodal Reentrant Tachycardia

2010

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“…4 Limited data suggest that manifest fusion during right ventricular entrainment of ORT using a nodal AP is specific to a nodoventricular fiber. 20 Because the circuit for NFRT is contained within the specialized conduction system, ventricular fusion cannot occur with paced complexes that penetrate the excitable gap and entrain tachycardia (analogous to AVNRT). Although this is true when collision between antidromic and orthodromic wavefronts occurs in the AV node or His bundle, it is not when the collision point is in the right bundle distal to the bifurcation of the His bundle and proximal to the take-off of the NF AP.…”

Section: Nodal Pathwaysmentioning

confidence: 99%

Electrophysiological Features Differentiating the Atypical Atrioventricular Node–Dependent Long RP Supraventricular Tachycardias

Frisch

Pavri

et al. 2013

Circ: Arrhythmia and Electrophysiology

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E stablishing the diagnosis of an atypical atrioventricular (AV) node-dependent long RP supraventricular tachycardia (SVT) can be difficult. Standard diagnostic criteria are lacking and often extrapolated from pacing maneuvers applied to the more common short RP SVT. Long RP SVTs involving concealed nodofascicular (NF) accessory pathways (AP) are particularly rare with descriptions limited to isolated case reports. [1][2][3][4] Prolonged conduction over the slow pathway (SP) of the AV node or a decremental AP after entrainment from the ventricle can produce A-A-V patterns that might be mistaken for atrial tachycardia (AT). 5 In addition, slow AP conduction after entrainment of an atypical orthodromic reciprocating tachycardia (ORT) can generate long postpacing intervals (PPI) that cause misdiagnosis of AV nodal reentrant tachycardia (AVNRT), despite correction for delay in the AV node (cPPI). [5][6][7] This study sought to evaluate the electrophysiological features and criteria differentiating the 4 atypical AV node-dependent long RP SVTs: atypical AVNRT, atypical AVNRT with a concealed, bystander NF AP (atypical AVNRT/NF AP), ORT using a concealed, slowly conducting, decremental AV AP (also called the permanent form of junctional reciprocating tachycardia [PJRT]), and ORT using a concealed NF AP (also called NF reentrant tachycardia [NFRT]

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“…Based on the evidence accruing from cases reported over the last decades, such arrhythmias are known to be less common than those produced by concealed nodofascicular pathways (Figure , lower panel; 17, 26, and 31). In this regard, an incessant tachycardia mediated by either a nodoventricular or a nodofascicular pathway, with ensuing arrhythmic‐induced cardiomyopathy, was reported by Quinn et al, with a series of three such patients reported more recently …”

Section: Introductionmentioning

confidence: 82%

“…It is now 38 years, nonetheless, since Gallagher et al were able to prove that an antegradely conducting nodoventricular pathway could be involved in an anatomical circuit producing an antidromic tachycardia. Subsequent to this report, multiple investigators have shown that concealed pathways, either originating from the atrioventricular node or the ventricular components of the axis, can function as the retrograde limb of orthodromic reciprocating tachycardias, as well as acting as “bystander” pathways during atypical atrioventricular nodal reentrant tachycardia . On occasion, the pathways can also act as bystanders in the antegrade limb of an atrioventricular nodal reentry tachycardia (AVNRT) .…”

Section: Introductionmentioning

confidence: 99%

Unusual variants of pre‐excitation: From anatomy to ablation: Part III—Clinical presentation, electrophysiologic characteristics, when and how to ablate nodoventricular, nodofascicular, fasciculoventricular pathways, along with considerations of permanent junctional reciprocating tachycardia

Correa

Lokhandwala²,

Sánchez‐Quintana

et al. 2019

Cardiovasc electrophysiol

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The recognition of the presence, location, and properties of unusual accessory pathways for atrioventricular conduction is an exciting, but frequently a difficult, challenge for the clinical cardiac arrhythmologist. In this third part of our series of reviews, we discuss the different steps required to come to the correct diagnosis and management decision in patients with nodofascicular, nodoventricular, and fasciculo‐ventricular pathways. We also discuss the concealed accessory atrioventricular pathways with the properties of decremental retrograde conduction that are associated with the so‐called permanent form of junctional reciprocating tachycardia. Careful analysis of the 12‐lead electrocardiogram during sinus rhythm and tachycardias should always precede the investigation in the catheterization room. When using programmed electrical stimulation of the heart from different intracardiac locations, combined with activation mapping, it should be possible to localize both the proximal and distal ends of the accessory connections. This, in turn, should then permit the determination of their electrophysiologic properties, providing the answer to the question “are they incorporated in a tachycardia circuit?”. It is this information that is essential for decision‐making with regard to the need for catheter ablation, and if necessary, its appropriate site.

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Entrainment Mapping of a Concealed Nodoventricular Accessory Pathway in a Man with Complete Heart Block and Tachycardia‐Induced Cardiomyopathy

Cited by 30 publications

References 20 publications

Atrioventricular Nodal Reentrant Tachycardia

Atrioventricular Nodal Reentrant Tachycardia

Electrophysiological Features Differentiating the Atypical Atrioventricular Node–Dependent Long RP Supraventricular Tachycardias

Unusual variants of pre‐excitation: From anatomy to ablation: Part III—Clinical presentation, electrophysiologic characteristics, when and how to ablate nodoventricular, nodofascicular, fasciculoventricular pathways, along with considerations of permanent junctional reciprocating tachycardia

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