Frequency, diagnosis and clinical characteristics of patients with multiple accessory atrioventricular pathways

Colavita, Paul G.; Packer, Douglas L.; Pressley, Joyce C.; Ellenbogen, Kenneth A.; O’Callaghan, William G.; Gilbert, M. R.; German, Lawrence D.

doi:10.1016/0002-9149(87)91177-5

Cited by 86 publications

(28 citation statements)

References 25 publications

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“…There were also certain preferred groupings of pathway locations in structural disease patients with multAP, most notably a TV + S combination in Ebstein’s malformation. 22 A genetic mutation affecting AV valve development could explain these observations. For example, the Nkx2.5/Alk3/BMPR pathway is involved in AV patterning and electrically-insulating annulus fibrosis formation.…”

Section: Discussionmentioning

confidence: 99%

Multiple accessory pathways in the young: The impact of structural heart disease

Zachariah

Walsh

Triedman

et al. 2013

American Heart Journal

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Background The presence of multiple accessory pathways (multAP) is described in structural heart disease (SHD) such as Ebstein’s anomaly and cardiomyopathies. Structural defects can impact the tolerability of tachyarrhythmia and can complicate both medical management and ablation. In a large cohort of pediatric patients with and without SHD undergoing invasive electrophysiology study, we examined the prevalence of multAP and the effect of both multAP and SHD on ablation outcomes. Methods Accessory pathway number and location, presence of SHD, ablation success, and recurrence were analyzed in consecutive patients from our center over a 16 year period. Results In 1088 patients, 1228 pathways (36% retrograde only) were mapped to the right side (TV) in 18%, septum(S) in 39%, and left side (MV) in 43%. MultAP were present in 111 pts (10%), involving 250 distinct pathways. SHD tripled the risk of multAP (26% SHD vs 8% no SHD, p<0.001). Multivariable adjusted risk factors for multAP included Ebstein’s(OR 8.7[4.4–17.5],p<0.001) and cardiomyopathy (OR13.3[5.1–34.5], p<0.001). Of 1306 ablation attempts, 94% were acutely successful with an 8% recurrence rate. Ablation success was affected by SHD (85% vs 95% for no SHD, p<0.01) but not by multAP (91% vs. 94% for single, p= 0.24). Recurrence rate was higher for SHD (17% SHD vs 8% no SHD, p<0.05) and multAP (19% multAP vs. 8% single, p<0.001). Conclusions MultAP are found in 10% of pediatric patients, and are more common in SHD compared to those with normal hearts. Both the presence of multAP and SHD negatively influence ablation outcomes.

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Section: Discussionmentioning

confidence: 99%

Multiple accessory pathways in the young: The impact of structural heart disease

Zachariah

Walsh

Triedman

et al. 2013

American Heart Journal

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“…13 Humans affected by an Ebstein anomaly may have multiple APs that are typically located in the right free wall or in the posterior part of the septum, locations that are more frequently described in dogs. 14,15 Most dogs that have APs are Labrador Retrievers and Boxers, suggesting a possible predisposition of these breeds to develop anomalous atrioventricular bundle connections. 2,13,16 In humans, APs allow antegrade and retrograde conduction with an all-or-none pattern.…”

Section: Discussionmentioning

confidence: 99%

ECG of the Month

Ra¹,

Critelli²,

Toaldo³

2010

javma

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A 2-year-old 30-kg (66-lb) sexually intact male Golden Retriever was referred to the Clinica Veterinaria Malpensa because of exercise intolerance and episodic weakness of 1 month' s duration. During 1 episode of weakness, an ECG examination performed by the primary veterinarian revealed a narrow-QRS complex tachycardia with a cycle length of 200 milliseconds. The patient was treated with sotalol a (2 mg/kg [0.9 mg/lb], PO, q 12 h) to control episodic supraventricular tachycardia and to reduce clinical signs.At the initial evaluation, a physical examination revealed no abnormalities. Findings of survey thoracic radiography and transthoracic echocardiography were considered normal. An initial 12-lead ECG revealed short PQ intervals, slurring of the onset of the QRS complexes (delta wave), and alteration of the QRS-ST segment morphology. These findings were consistent with ventricular pre-excitation.The presence of an accessory pathway (AP)-mediated tachycardia was strongly suspected, and an electrophysiological assessment was performed. Sotalol administration was discontinued for 24 hours (ie, a period equivalent to 5 half-lives of the drug) before the procedure. The patient was anesthetized and placed in dorsal recumbency during the entire interventional procedure. Multiple access sites on jugular and femoral veins were used to allow introduction of endocardial catheters by use of the Seldinger technique. The electrophysiological assessment was conducted in accordance with standard techniques. 1,2 A decapolar catheter b was introduced at the level of the coronary sinus and positioned in contact with the epicardal surface, and a quadripolar catheter c was inserted near the bundle of His. An ablation catheter d was used to perform programmed atrial and ven- Figure 1-Surface ECG tracings (6 leads of a 12-lead ECG) obtained during electrophysiological assessment of a dog that was evaluated because of exercise intolerance and episodic weakness of 1 month's duration. On the basis of initial ECG findings, an accessory pathway (AP) was suspected. The electrophysiological examination revealed the presence of an AP that was subsequently ablated by use of a radiofrequency catheter. During the procedure and before the ablation, the dog developed a paroxysm of sustained atrial fibrillation (AF). The first 6 beats of the ECG tracings have features typical of AF with orthodromic conduction through the His-Purkinje system, including absence of the P wave, narrow QRS complex (duration, 60 milliseconds; reference range, < 70 milliseconds), and irregular R-R intervals. From the seventh beat onward, antegrade activation of the AP with signs of ventricular pre-excitation is evident. Wide QRS complexes (duration, 100 milliseconds), the presence of a delta wave preceding each R wave, and persistence of irregular R-R intervals are indicative of the occurrence of pre-excited AF. Paper speed = 50 mm/s; 1 cm = 1 mV.

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“…4 In around 10% of cases multiple pathways exist. 5 The incidence of associated congenital abnormalities ranges from 7% to 20%. 3 6 Tricuspid valve lesions are the most common.…”

Section: Discussionmentioning

confidence: 99%