Cryoablation of the accessory pathway in Wolff-Parkinson-White syndrome: initial results and long term follow up.

Cryoablation of the accessory pathway was used in the management of 20 patients with pre-excitation syndromes. All patients had presented with paroxysmal atrioventricular reentrant tachycardia; in addition, six had experienced atrial fibrillation. In 16 patients pre-excitation was overt and in four the accessory pathway was concealed. Intraoperative epicardial and endocardial mapping showed 10 left free wall pathways, seven septal pathways, and four right free wall pathways. One patient had two right free wall accessory pathways. There was one postoperative death (from a ruptured cerebral haemangioma) and one patient had transient hemiparesis. There was early recurrence of arrhythmia or pre-excitation in six patients and five of these were among the first ten in the series. Four of the six underwent successful reoperation; 17 patients remain symptom free of all antiarrhythmic treatment. Two patients did not undergo reoperation--one became symptom free on drugs that had previously been ineffective and the other received an antitachycardia pacemaker. The mean period of follow up was six years. Accessory pathway function was not restored and atrioventricular nodal function was preserved in all patients, demonstrating the feasibility of this technique in the long term management of patients with the pre-excitation syndrome.     

Mechanisms of junctional tachycardia showing ventricular pre-excitation.

Over a period of five years 12 patients underwent electrophysiological studies for the investigation of recurrent tachycardias which showed ventricular pre-excitation. Nine patients had a type B pattern and two a type A. One patient had episodes of both types. Dual atrioventricular nodal pathways were found in six of seven patients with atrioventricular nodal re-entrant tachycardia mechanisms. Single direct atrioventricular accessory pathways were present in four patients, single nodoventricular pathways in five, and multiple pathways in three. Twenty one tachycardias were induced, of which 13 showed ventricular pre-excitation. Five patients had nodoventricular pathway conduction during atrioventricular nodal tachycardia and one during atrioventricular re-entrant tachycardia. Only three patients had simple antidromic tachycardia and one additional atrioventricular nodal tachycardia with bystander atrioventricular accessory conduction. Three patients had three different tachycardias, three had two types, and six had one type. Thus junctional tachycardias showing ventricular pre-excitation are often associated with multiple mechanisms and complex anatomical and functional substrates. An accessory pathway was an essential component in only six of 13 tachycardias showing ventricular pre-excitation. Determination of the tachycardia mechanism requires detailed study and analysis.     

Mechanisms of junctional tachycardia showing ventricular pre-excitation

Over a period of five years 12 patients underwent electrophysiological studies for the investigation of recurrent tachycardias which showed ventricular pre-excitation. Nine patients had a type B pattern and two a type A. One patient had episodes of both types. Dual atrioventricular nodal pathways were found in six of seven patients with atrioventricular nodal re-entrant tachycardia mechanisms. Single direct atrioventricular accessory pathways were present in four patients, single nodoventricular pathways in five, and multiple pathways in three. Twenty one tachycardias were induced, of which 13 showed ventricular pre-excitation. Five patients had nodoventricular pathway conduction during atrioventricular nodal tachycardia and one during atrioventricular re-entrant tachycardia. Only three patients had simple antidromic tachycardia and one additional atrioventricular nodal tachycardia with bystander atrioventricular accessory conduction. Three patients had three different tachycardias, three had two types, and six had one type. Thus junctional tachycardias showing ventricular pre-excitation are often associated with multiple mechanisms and complex anatomical and functional substrates. An accessory pathway was an essential component in only six of 13 tachycardias showing ventricular pre-excitation. Determination of the tachycardia mechanism requires detailed study and analysis.     

Radiofrequency catheter ablation of Mahaim tachycardia by targeting Mahaim potentials at the tricuspid annulus.

BACKGROUND--Reentrant tachycardias associated with Mahaim pathways are rare but potentially troublesome. Various electrophysiological substrates have been postulated and catheter ablation at several sites has been described. OBJECTIVE--To assess the efficacy and feasibility of targeting discrete Mahaim potentials recorded on the tricuspid annulus for the delivery of radiofrequency energy in the treatment of Mahaim tachycardia. PATIENTS--21 patients out of a consecutive series of 579 patients referred to one of three tertiary centres for catheter ablation of accessory pathways causing tachycardia. All had symptoms and presented with tachycardia of left bundle branch block configuration or had this induced at electrophysiological study. In all cases, the tachycardia was antidromic with anterograde conduction over a Mahaim pathway. RESULTS--6 patients had additional tachycardia substrates (4 had accessory atrioventricular connections and 2 had dual atrioventricular nodal pathways and atrioventricular nodal reentry). After ablation of the additional pathways, Mahaim potentials were identified in 16 (76%) associated with early activation of the distal right bundle branch and radiofrequency energy at this site on the tricuspid annulus abolished Mahaim conduction in all 16 cases. In 2 patients there was early ventricular activation at the annulus without a Mahaim potential but radiofrequency energy abolished pre-excitation. In the remaining patients no potential could be found (1 patient), no tachycardia could be induced after ablation of an additional pathway (1 patient), or no Mahaim conduction was evident during the study (1 patient). During follow up (1-29 months (median 9 months)) all but 1 patient remained symptom free without medication. CONCLUSIONS--Additional accessory pathways seem to be common in patients with Mahaim tachycardias. The identification of Mahaim potentials at the tricuspid annulus confirms that most of these pathways are in the right free wall and permits their successful ablation and the abolition of associated tachycardia.     

Treatment of tachycardias associated with the Wolff-Parkinson-White syndrome by transvenous electrical ablation of accessory pathways.

Three patients with tachycardias associated with the Wolff-Parkinson-White syndrome had failed to respond to antiarrhythmic drugs and underwent transvenous ablation of accessory pathways. Intracardiac studies located the site of accessory pathway to the septum in two patients and mid-posterobasal left atrioventricular junction in one. Ablation was performed by positioning an electrode lead as close as possible to the accessory tract and delivering shocks of 50 to 100J using a conventional defibrillator. In all patients the accessory pathway was abolished after the first three shocks. In two patients followed for four and nine months there was no recurrence of tachycardia or pre-excitation. The other patient developed pre-excitation again three weeks later and repeat ablation was performed. This patient has been followed for six months with no evidence of a recurrence of pre-excitation. This method may provide a valuable alternative to pacemaker and surgical treatment in selected patients with drug resistant arrhythmias associated with accessory atrioventricular connexions.     

Surgery for Wolff-Parkinson-White syndrome: further experience with an epicardial approach

We have previously reported the use of an epicardial approach for ablation of left ventricular free wall accessory atrioventricular pathways. The technique involves mobilization of the atrioventricular fat pad and exposure and cryoablation of the atrioventricular junction at the site of the accessory pathway on the normothermic beating heart. Here we describe our further experience with left ventricular free wall accessory pathways and right ventricular free wall accessory pathways. Our experience is based on 53 consecutive patients. There were 35 male and 18 female subjects, 6 to 52 (mean 41.4) years old. Forty-eight patients had a left ventricular free wall accessory pathway, and five had a right ventricular free wall accessory pathway. Two patients had an associated anterior septal accessory pathway. Five patients had associated cardiac abnormalities, including atrial septal defect, aortic insufficiency, mitral valve prolapse, Ebstein's anomaly, and cardiomyopathy. The accessory pathway was ablated in 52 patients who remain arrhythmia free without medication after a mean follow-up period of 12 months. The accessory pathway was permanently modified in one patient. There were no postoperative complications. This epicardial approach can be performed with normothermic cardiopulmonary bypass or without bypass. It does not require cross-clamping of the aorta, allowing a greater margin of safety when this is required for concomitant procedures.     

Treatment of tachycardias associated with the Wolff-Parkinson-White syndrome by transvenous electrical ablation of accessory pathways

Three patients with tachycardias associated with the Wolff-Parkinson-White syndrome had failed to respond to antiarrhythmic drugs and underwent transvenous ablation of accessory pathways. Intracardiac studies located the site of accessory pathway to the septum in two patients and mid-posterobasal left atrioventricular junction in one. Ablation was performed by positioning an electrode lead as close as possible to the accessory tract and delivering shocks of 50 to 100J using a conventional defibrillator. In all patients the accessory pathway was abolished after the first three shocks. In two patients followed for four and nine months there was no recurrence of tachycardia or pre-excitation. The other patient developed pre-excitation again three weeks later and repeat ablation was performed. This patient has been followed for six months with no evidence of a recurrence of pre-excitation. This method may provide a valuable alternative to pacemaker and surgical treatment in selected patients with drug resistant arrhythmias associated with accessory atrioventricular connexions.     

Surgical treatment of accessory atrioventricular pathways and symptomatic tachycardia in children and young adults

Twenty-seven patients aged 21 years or younger (mean 15) with symptomatic tachycardia underwent operation for ablation of an accessory atrioventricular pathway. Six patients had associated Ebstein's malformation of the tricuspid valve. Supraventricular tachycardia had been present for a mean of 5 years. At electrophysiologic study, 4 patients were found to have 2 accessory pathways. Left ventricular free wall pathways were found In 14 patients, right ventricular free wall pathways in 10 and septal pathways in 6. Successful initial ablation of all the pathways was achieved in 26 of the 27 patients. No patient died perioperatively and none had persistent complete heart block. During a mean follow-up of 11 months, no patient had recurrence of an arrhythmia related to the accessory pathway. Thus, the surgical treatment of children and young adults with accessory atrioventricular pathways and symptomatic supraventricular tachycardia is safe and effective. For these patients, unless the tachycardia can be easily controlled with a minimal number of drugs and adverse effects, surgical ablation should be considered early in the clinical course.     

The electrophysiologic basis and management of symptomatic recurrent tachycardia in patients with ebstein's anomaly of the tricuspid valve

Twenty-two patients with Ebstein's anomaly were evaluated because of recurrent tachycardia. A total of 30 accessory pathways were present in 21 of the 22 patients. Twenty-six accessory pathways were of the atrioventricular (A-V) type while four were Mahaim fibers. Multiple accessory pathways were present in eight patients. Twenty-five of the 26 accessory A-V pathways were right-sided, either in the posterior septum (12 pathways) or the posterolateral free wall (13 pathways); one patient with corrected transposition of the great arteries had a left-sided accessory A-V pathway in a lateral free wall location. Patients with accessory A-V pathways had a long minimal ventriculoatrial (V-A) conduction time during reciprocating tachycardia (192 ± 47 ms) and usually showed a persistent complete or incomplete right bundle branch block morphology.At surgery, preexcitation was invariably localized to the atrialized ventricle. The long V-A conduction time during reciprocating tachycardia appeared to consist of late activation of the local ventricle in the region of the accessory pathway with a further delay occurring before excitation of adjacent atrium presumably due to conduction over the accessory pathway. Accessory A-V pathways were successfully sectioned with no deaths in 13 of 15 patients.On the basis of these data, certain electrocardiographic findings encountered in the study of patients with recurrent tachycardia should point to the possibility of associated Ebstein's anomaly: morphology of the surface electrocardiogram suggesting preexcitation of the right posterior septum or right posterolateral free wall as well as the combination during reciprocating tachycardia of a long V-A interval and right bundle branch block.     

Usefulness of predischarge electrophysiologic study in predicting late outcome after surgical ablation of the accessory pathway in the Wolff-Parkinson-White syndrome.

A predischarge electrophysiologic study was performed in 113 patients with the Wolff-Parkinson-White (WPW) syndrome who had undergone surgical ablation of the accessory pathway. The study was performed 5 to 20 (mean 10 +/- 3) days after surgery. There were 82 male and 31 female patients (aged 4 to 58 years, mean 36 +/- 13). Sixty-one patients (54%) had manifest, 52 (46%) had concealed and 12 (11%) had multiple accessory pathways. All but 1 patient had atrioventricular reentrant tachycardia incorporating single or multiple accessory pathways during the control electrophysiologic study. The accessory pathways were located in the left ventricular free wall in 60% of cases, right ventricular free wall in 22%, posteroseptum in 13%, and anteroseptum in 5%. The predischarge electrophysiologic study showed that the accessory pathway was capable of anterograde and retrograde conductions in 4 patients (all with manifest WPW syndrome). Four patients showed induction of supraventricular tachycardia, including 2 with atrioventricular reentrant tachycardia, and 2 with atrioventricular nodal reentrant tachycardia. Recurrence of supraventricular tachycardia was noted in 5 patients during a follow-up of 28 +/- 26 months. Of these 5 patients, 2 had inducible and 3 had no inducible supraventricular tachycardia during the predischarge electrophysiologic study.(ABSTRACT TRUNCATED AT 250 WORDS)     

Clinical experience with surgery for paroxysmal supraventricular tachycardia: a report of 103 cases

One-hundred-and-three patients underwent surgery for paroxysmal supraventricular tachycardia (PSVT). In eighty-three patients (81%), PSVT was due to an accessory atrioventricular pathway (Group I) and in 20 (19%) to Atrioventricular Junctional (AV nodal) Reentrant Tachycardia (AVJRT:Group II). Initial surgery successfully divided 77 of 83 accessory pathways, including 58 of 60 left free wall pathways, 12 of 15 posteroseptal pathways, six of seven right free wall pathways and one anteroseptal pathway. Twenty patients had successful surgery for AVJRT. Surgery was performed with low morbidity and no early or late mortality in either group. One patient in each group required permanent pacemaker implantation. Immediate (within one week) postoperative electrophysiological study using epicardial wires was performed in 96% of patients and repeat electrophysiological study six months later was possible in 65/103 (63%) patients. Patients with surgery for accessory pathways were followed-up for a mean 34 ± 23 months, while those with surgery for AVJRT for a mean of 13 ± seven months. No patient with successful surgery has had a clinical recurrence of PSVT. Thus the results indicate that surery is a safe and curative therapy for patients with PSVT. (Aust NZ J Med 1992; 22: 134–138.)     

Initial forces of ventricular depolarization in the Wolff-Parkinson-White Syndrome. Analysis based upon localization of the accessory pathway by epicardial mapping.

The epicardial activation sequence of 34 patients with the Wolff-Parkinson-White syndrome was determined. Epicardial pre-excitation occurred at a spectrum of sites over either the free wall of the left or right ventricle or in a paraseptal region, always adjacent to the atrioventricular rings. The site of pre-excitation was related to the spatial position of the 10 msec vector of the vectorcardiogram (VCG) in 15 patients and the 20 msec vector of the electrocardiogram (ECG) in 29 patients with a single accessory pathway. All patients whose 20 msec vector (ECG) was directed to the right had accessory pathways which caused epicardial breakthrough over the free wall of the left ventricle. When the 20 msec vector (ECG) was to the left and inferior, epicardial pre-excitation was over either the right ventricular free wall or in the region of the pulmonary outflow tract. Superior location of the initial forces, especially the 10 msec vector (VCG), strongly suggested the presence of a septal bypass tract. The polarity of the delta wave and maximum QRS forces in precordial lead V1 were discordant in a significant number of patients, pointing to probable shortcomings of a classification based upon the latter.     

The catheter ablation of accessory atrioventricular pathways using a radiofrequency]

Sixteen consecutive patients (5 males and 11 females) aged 40 +/- 22 years suffering for spontaneous symptomatic arrhythmias underwent attempted transcatheter ablation of an atrioventricular accessory pathway using radiofrequency current. Five patients had the WPW syndrome. The Kent bundle was located in the left free wall in 14 patients, in the right anteroseptal region in one patient and in the posteroseptal zone in one patient. A 7F catheter (Polaris, Mansfield) with a 4 mm2 distal electrode, was used for ablation positioned on the left atrioventricular annulus in the 13 patients with left free wall accessory pathways or at the right atrium in the two patients with right accessory pathways. Without general anesthesia, a mean of 12 +/- 9 applications of radiofrequency current were delivered between the large tip electrode and a large skin patch positioned on the left posterior chest. By using radiofrequency current, a successful clinical outcome was achieved in 14 of 16 patients (87%). In patients with concealed accessory pathways, accessory conduction was abolished in 10 of 11 patients, in 8 patients in the first radiofrequency session and in two other patients in a successful second procedure. In the 5 patients with the WPW syndrome, the anterograde conduction disappeared after the procedure but the retrograde conduction remained, although deteriorated, in 2 patients. One patient developed uncomplicated tibioperoneal thrombophlebitis and in 2 cases an elevated concentration of creatine kinase value was found. In one female patient with a concealed accessory pathway, the Kent bundle conduction reappeared 3 months after the procedure and was ablated in a second session.(ABSTRACT TRUNCATED AT 250 WORDS)     

Surgical treatment of supraventricular tachycardia in infants and children

The technique, indications and results of surgical division of accessory atrioventricular connections in 10 infants and children with drug-resistant Supraventricular tachycardia are described. The patients ranged in age from 6 months to 15 years. Four patients had associated congenital heart disease. Division of accessory connections were performed on free wall pathways in nine patients (seven right atrial, two left atrial) and on a septal pathway in one patient. Four patients had both anterograde and retrograde conduction over the accessory connection (manifest Wolff-Parkinson-White conduction) whereas six had only retrograde conduction (concealed Wolff-Parkinson-White conduction). The manifest Wolff-Parkinson-White conduction was abolished by surgical division in all four patients. In 8 of the 10 patients the procedure stopped the attacks of paroxysmal supraventricular tachycardia for follow-up periods ranging from 9 months to 3 $\text{1}\text{2}$ years; no patient receives medication to date.     

Early and late results of surgery for Wolff-Parkinson-White syndrome

Surgical treatment for accessory atrioventricular connections was performed in 60 patients with Wolff-Parkinson-White syndrome between 1981 and 1986. The initial procedure successfully divided 69 of 73 pathways identified preoperatively, including 39 of 40 left free wall pathways, 23 of 24 posteroseptal pathways, six of seven right free wall pathways, and one of two anteroseptal pathways. Three additional pathways were identified for the first time during follow-up. The primary procedure was successful in curing 53 (88%) of the 60 patients and in dividing 69 (91%) of the total of 76 pathways. Subsequent procedures increased the overall clinical cure rate to 97%. The surgery was performed with low morbidity and no perioperative or late mortality. Patients were followed-up for a mean of 6.4 years (range four to nine years). No patient showed clinical or electrocardiographic evidence of recurrence of a pathway which had been divided surgically. We conclude that regardless of pathway site, surgical treatment carries a low risk and has a high probability of avoiding lifelong antiarrhythmic therapy.     

Electrophysiological action of bepridil on atrioventricular accessory pathways.

The electrophysiologic properties of bepridil, a calcium channel blocker with additional effects on fast response tissues, were investigated in 10 patients with atrioventricular accessory pathways. Seven patients had Wolff-Parkinson-White syndrome, and three had concealed atrioventricular pre-excitation. A dose of 4 mg/kg was administered intravenously over five minutes. Bepridil increased the AH interval and the functional refractory period of the atrioventricular node. The effective refractory periods of the right atrium and right ventricle were also increased. Bepridil prolonged refractoriness in the accessory pathway both in the anterograde and retrograde direction. After bepridil administration it was impossible to induce reciprocating tachycardia electrically in two patients because of conduction block in the normal pathway. On the other hand, the zone of tachycardia was often increased after bepridil. Nevertheless, the heart rate during tachycardia was slowed by depression of conduction in both the normal and accessory pathways. The findings of this study provide a basis for the antiarrhythmic action of bepridil in patients with atrioventricular accessory pathways.     

射频消蚀治疗预激综合征81例报告

以射频电流对81例预激综合征伴阵发性室上性心动过速患者的房室旁路进行消蚀。76例(93.8％)患者的83条旁路(94.3％)被阻断。平均放电12次,平均消蚀时程2.3小时,随访7个月,2例(2.5％)复发但成功地进行第二次消蚀,无严重并发症。     

Electrophysiological action of bepridil on atrioventricular accessory pathways

The electrophysiologic properties of bepridil, a calcium channel blocker with additional effects on fast response tissues, were investigated in 10 patients with atrioventricular accessory pathways. Seven patients had Wolff-Parkinson-White syndrome, and three had concealed atrioventricular pre-excitation. A dose of 4 mg/kg was administered intravenously over five minutes. Bepridil increased the AH interval and the functional refractory period of the atrioventricular node. The effective refractory periods of the right atrium and right ventricle were also increased. Bepridil prolonged refractoriness in the accessory pathway both in the anterograde and retrograde direction. After bepridil administration it was impossible to induce reciprocating tachycardia electrically in two patients because of conduction block in the normal pathway. On the other hand, the zone of tachycardia was often increased after bepridil. Nevertheless, the heart rate during tachycardia was slowed by depression of conduction in both the normal and accessory pathways. The findings of this study provide a basis for the antiarrhythmic action of bepridil in patients with atrioventricular accessory pathways.     

Electrocardiographic and electrophysiologic characteristics of anterior, midseptal and right anterior free wall accessory pathways.

OBJECTIVES. The objective of this study was to define the electrocardiographic (ECG) and electrophysiologic characteristics of midseptal, anteroseptal and right anterior free wall accessory pathways. METHODS. The fully pre-excited 12-lead surface ECGs and ECGs during orthodromic atrioventricular (AV) reentrant tachycardia were compared for 13 patients with an anteroseptal, 7 with a midseptal and 7 with a right free wall accessory pathway. Routine electrophysiologic studies were performed in all and stimulation of the right ventricular summit during tachycardia was accomplished in 10 patients. RESULTS. Differences in the surface ECGs were not sufficiently sensitive to distinguish among accessory pathway locations. Premature ventricular complexes induced from the right ventricular septal summit during ventricular activation either advanced the succeeding atrial depolarization or terminated the tachycardia in three of six patients with a septal pathway and in none of the four with a right anterior pathway. The change in ventriculoatrial (VA) interval with the development of right bundle branch block during orthodromic AV tachycardia proved most helpful in distinguishing these pathways. Patients with a right anterior free wall pathway showed a change in VA interval > or = 40 ms, whereas those with an anteroseptal pathway showed changes of 20 to 30 ms and those with a midseptal pathway showed no change. CONCLUSIONS. Anteroseptal, midseptal and right anterior free wall pathways may be distinguished by using programmed stimulation of the summit of the right ventricular septum and especially with changes in the VA interval with development of right bundle branch block during orthodromic AV reentrant tachycardia.     

Simultaneous mapping of the tricuspid and mitral valve annuli at electrophysiological study.

BACKGROUND--Mapping of the right free wall in patients with accessory pathways is difficult compared with that of the left free wall where the coronary sinus permits stable and accurate location of the electrodes used for endocardial mapping. Furthermore, the sequential roving catheter method is less satisfactory than multiple simultaneous electrode recordings spanning the circumference of the valve annulus. A new method for mapping the tricuspid annulus is described. METHODS--Mapping was performed in nine patients with a suspected right free wall accessory pathway or an atriofascicular connection. The tricuspid annulus was mapped using a specially shaped 1 cm interelectrode 10 pole catheter positioned in the right atrium immediately above the annulus. The coronary sinus was mapped with a 5 mm interelectrode 10 pole catheter and a 2 mm interelectrode 10 pole catheter recorded His bundle activity. Catheter positions were confirmed by multiplane fluoroscopy. Electrograms were digitised and recorded simultaneously using a custom computerised mapping system. The position of the multielectrode catheter around the tricuspid annulus relative to that of the coronary arteries was examined by coronary angiography in three patients. RESULTS--Seven right free wall and two posterior septal accessory pathways, and three atriofascicular connections were detected. Ventricular activation adjacent to both valve annuli was mapped in five patients with pre-excitation. The locations of eight of the nine accessory pathways and the three atriofascicular connections were confirmed at operative mapping. One right free wall accessory pathway in a patient with Ebstein's anomaly was not detected at operative mapping. No additional accessory pathways were found at operative mapping or routine 6 month postoperative electrophysiological study, or during a mean (SD) clinical follow up of 22 (7) months. The tricuspid annulus catheter was located during coronary angiography at a mean (SD) of about 2.5 (0.7) cm above and parallel to the right coronary artery in the right atrioventricular groove. CONCLUSIONS--This new catheter technique permits rapid detailed mapping of atrial and ventricular activation around the tricuspid annulus with a resolution of at least < or = % 1 cm, depending on the number and spacing of electrodes in each catheter. The technique was accurate as judged by mapping at surgery. This method is simple and safe compared with that of others for mapping the right free wall via the right coronary artery. It should facilitate detection and ablation of right free wall accessory pathways and atriofascicular connections.