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1 ISSN The Official Journal of Korean Heart Rhythm Society Vol.12 No.2 June 2011 부정맥 부정맥 The Official Journal of Korean Heart Rhythm Society 발작성 심실상성 빈맥(PSVT)(II ) Main Topic Reviews 발작성 심실상성 빈맥의 약물 치료 심실상성 빈맥의 감별진단을 위한 방법 심실상성 빈맥의 도자절제술 Fluoroscopic anatomy for supraventricular tachycardia ablation 흔하지 않은 종류의 심실상성 빈맥 Article Review ipsc: 진단과 치료의 새로운 패러다임 ECG & EP Cases 심박동기 전극선과 관련된 감염성 심내막염 Catheter ablation for AV nodal reentrant tachycardia in absent right and persistent left SVC 발현성 및 잠복성 부전도로를 가진 비후성 심근병증 환자의 전극도자 절제술 심방세동을 동반한 발작성 역방향 방실 회귀성 빈맥 심방세동 중 정방향 좌측 방실부전도의 도자절제술 발작성 심실상성 빈맥의 진단에 도움이 되는 심전도 소견 Vol.12 No.2 통권 37호 June 2011

2 Journal of Cardiac Arrhythmia Copyright 2011 Journal of Cardiac Arrhythmia Editorial Board & MMK Co., Ltd. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise without permission in written form from the copyright holder. This publication is published by MMK Co., Ltd.

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5 Journal of Cardiac Arrhythmia Vol.12 No.2 June 2011 Contents Cover: Koch slow conduction and the anatomic structure of the triangle as the location of the catheter for resection (p.15) II Main Topic Reviews Article Review ECG & EP Cases

6 MAIN TOPIC REVIEWS Nam-Sik Yoon, MD Division of Cardiology, Department of Internal Medicine, Medical School, Chonnam National University, Gwangju, Korea Management of SVT (Medical treatment) ABSTRACT Paroxysmal supraventricular tachycardia, PSVT, involves the AV node for occurrence and maintenance of tachycardia and responds to AV nodal blocking agent such as adenosine, calcium-channel blocker (verapamil, diltiazem) and beta-blocker (propranolol, esmolol). Medication is given for patients with frequent recurrences and critical symptoms in order to prevent repetition. The medication (anti-arrhythmic agent) schedule is decided upon according to the mechanism of the PSVT, the performance status of the patient, the electrophysiological characteristics of drug and how much the physician is familiar with the medication. Key words: paroxysmal supraventricular tachycardia anti arrhythmic agent Received: February 16, 2011 Revision Received: June 20, 2011 Accepted: June 29, 2011 Correspondence: Nam-Sik Yoon, MD, Division of Cardiology, Department of Internal Medicine, Medical School, Chonnam National University, 671 Jeabongro, Dong-gu, Gwangju, Korea Tel: , Fax: Journal of Cardiac Arrhythmia

7 Table 1. Vaughan-Williams Classification Class I (Sodium Channel Blocker) Ia : Procainamide, Quinidine Ib : Lidocaine, Mexiletine, Disopyramide Ic : Flecainde, Propafenone Class II (Beta-Blocker) Propranolol, Esmolol, Atenolol, Metoprolol Class III (Potassium Channel Blocker) Amiodarone, Sotalol Class IV (Calcium Channel Blocker) Verapamil, Diltiazem, Nifedipine Digoxin, Adenosine Table 2. Reclassified according to the site of action of antiarrhythmic drug Calcium-Channel dependent tissue (SA Node & AV Node) : Beta-Blocker (Class II), Calcium Channel Blocker (Class IV), Digoxin, Adenosine Sodium-Channel dependent tissue (Atrial & Ventricular Myocardium, Accessory pathway, Specialized Conduction System -His bundle, Bundle Branch, Purkinje fiber) : Sodium Channel Blocker (Class Ia) Both : Class Ic, Class III MAIN TOPIC REVIEWS VOL.12 NO.2 5

8 MAIN TOPIC REVIEWS References 1. Choi YS. Pharmacological Therapy of Paroxysmal Supraventricular Tachycardia. The Korean Journal of Internal Medicine. 1990;39(6): Rinne C, Klein GJ, Sharma AD, Yee R, Milstein S, Rattes MF: Relationship between clinical presentation and induced arrhythmia in the Wolff-Parkinson-White syndrome. Am J Cariol. 1987;60: Josephson ME. Clinical Cardiac Electrophysiology. 3rd ed. Lippincott Williams & Wilkins; Zipes DP, Jalife J, Cardiac Electrophysiology from cell to bedside. 5th ed. Saunders; Journal of Cardiac Arrhythmia

9 MAIN TOPIC REVIEWS Kyoung-Min Park, MD, PhD Department of Internal Medicine, Sanggye-Paik Hospital, University of Inje College of Medicine, Seoul, Korea Diagnostic maneuvers for differentiation of supraventricular tachycardias ABSTRACT There are three primary mechanisms of paroxysmal supraventricular tachycardia (PSVT). First, atrioventricular nodal reentrant tachycardia (AVNRT; > 65%), second, atrioventricular reciprocating tachycardia (orthodromic AVRT=ORT; < 30%), and third, atrial tachycardia (AT; 5%). For the successful ablation of supraventricular arrhythmias, it is essential to differentiate between focal AT and the other types of reentrant supraventricular tachycardias (SVTs), namely AVNRT and ORT. Typically, baseline findings, tachycardia characteristics, and ventricular and atrial pacing maneuvers during tachycardia are used for the purpose of reaching the differential diagnosis of supraventricular arrhythmias. Key words: diagnostic maneuvers supraventricular tachycardia Para-Hisian pacing entrainment Introduction Received: February 6, 2011 Accepted: June 29, 2011 Correspondence: Kyoung-Min Park, MD, PhD, Cardiac Electrophysiology Laboratories, Hospital of the University of Pennsylvania, Philadelphia, PA, USA, Department of Internal Medicine, Sanggye-Paik Hospital, University of Inje College of Medicine, Seoul, Korea Tel: VOL.12 NO.2 7

10 MAIN TOPIC REVIEWS Baseline Findings Methods 8 Journal of Cardiac Arrhythmia

11 A RV+HB-RB Capture B RV+HB-RB Capture C Fast pathway Accessory pathway AVN Fast Pacing site pathway Pacing site CS Slow pathway CS CS RV+HB-RB Capture Pacing site Accessory pathway MAIN TOPIC REVIEWS RV Capture RV Capture RV Capture Accessory pathway Accessory pathway HB RB RB RB AVN AVN HB AVN CS Fast pathway HB CS CS AVN RB HB RB HB RB CS Slow pathway CS CS Retrograde conduction AV node AP AV node and AP Atrial sequence Identical Identical Changes S-A interval Longer Same Longer (near the AV node) H-A interval Same Shorter Same or shorter Figure 1. Schematic presentation of response patterns to para-hisian pacing between conduction over the AV node alone (A), conduction over an accessory pathway alone (B), and conduction over the AV node and accessory pathway combined (C). AP; accessory pathway, H-A; His-atrial, S-A; stimulus-atrial Measures Tachycardia Characteristics VOL.12 NO.2 9

12 MAIN TOPIC REVIEWS Maneuvers during Tachycardias Atrial pacing 1. Pace the A during SVT at a CL 10~40 ms < SVT CL 2. Pace the A during SVT at the AV block CL 3. Scan diastole with a premature atrial extrastimulus Ventricular pacing 1. Pace the V during SVT at a CL 10~40 ms < SVT CL 2. Pace the V during SVT at a CL 200~250 ms for 3~6 beats 3. Scan diastole with a premature ventricular extrastimulus 10 Journal of Cardiac Arrhythmia

13 Pacing Maneuver Observation Interpretation Pacing Maneuver Observation No Entrainment Yes It is because the SVT always Is the atrial activation the terminates or because the same as during SVT? VA block cycle length during Is the response or cessation SVT is > SVT cycle length? of pacing A-A-V or Did the tachycardia A V? terminate without an effect Is the PPI-TCL > or < 115 on the atrium? msec? MAIN TOPIC REVIEWS VOL.12 NO.2 11

14 MAIN TOPIC REVIEWS V1 I S S II III HRA HBd VA = 440 ms S-A = 480 ms RVA TCL = 470 ms PPI = 550 ms A 200 ms B Figure 2. Entrainment of orthodromic reciprocating tachycardia (ORT) using a right posteroseptal bypass tract from the right ventricular apex at a cycle length of 440 msec. The ventriculo-atrial (VA) interval and tachycardia cycle length (TCL) are measured immediately before entrainment (A). The stimulus-atrial (S-A) interval is measured from the last pacing stimulus to the last entrained high right atrial (HRA) electrogram, and the post-pacing interval (PPI) is measured from the last pacing stimulus to the return cycle RV electrogram (B). The S-A-VA interval is 40 msec, and PPI-TCL is 80 msec. Differential Diagnosis of PSVT in the EP Laboratory References 1. Souza JJ, Zivin A, Flemming M, Pelosi F, Oral H, Knight BP, Goyal R, Man KC, Strickberger SA, Morady F. Differential effect of adenosine on anterograde and retrograde fast pathway 12 Journal of Cardiac Arrhythmia

15 Septal VA interval < 70 Yes No Yes Eccentric atrial activation No MAIN TOPIC REVIEWS Entrain from RV Entrain from RV Entrain from RV VAV Cannot entrain VAAV VAV Cannot VAAV VAV Cannot entrain entrain VAAV Term w/o atrial preexcitation Term w/o atrial preexcitation Term w/o atrial preexcitation Yes No Yes No Yes No Yes VA linking No Yes VA linking No Yes VA linking No PPI-TLC<115 VPC/His to A Yes No Yes No AVNRT AT ORT AT ORT AVNRT AT Figure 3. Flow-chart for differential diagnosis of PSVT in the EP laboratory. AT; atrial tachycardia, AVNRT; atrioventricular nodal reentrant tachycardia, ORT; orthodromic reciprocating tachycardia, PPI; post-pacing interval, TCL; tachycardia cycle length, VA; ventriculo-atrial, VPC; ventricular premature contraction conduction in patients with atrioventricular nodal reentrant tachycardia. J Cardiovasc Electrophysiol. 1998;9: Nakagawa H, Jackman WM. Para-Hisian pacing: Useful clinical technique to differentiate retrograde conduction between accessory atrioventricular pathways and atrioventricular nodal pathways. Heart Rhythm. 2005;2: Nam GB, Rhee KS, Kim J, Choi KJ, Kim YH. Left atrionodal connections in typical and atypical atrioventricular nodal reentrant tachycardias. J Cardiovasc Electrophysiol. 2006;17: Hwang Chun, Martin DJ, Goodman JS, Gang ES, Mandle WJ, Swerdlow CD, Peter CT, Chen PS. Atypical atrioventricular node reciprocating tachycardia masquerading as tachycardia using a left-sided accessory pathway. J Am Coll Cardiol. 1997;30: Michaud GF, Tada H, Chough S, Baker R, Wasmer K, Sticherling C, Oral H, Pelosi F, Knight BP, Strickberger SA, Morady F. Differentiation of atypical atrioventricular node re-entrant tachycardia from orthodromic reciprocating tachycardia using a septal accessory pathway by the response to ventricular pacing. J Am Coll Cardiol. 2001;38: VOL.12 NO.2 13

16 MAIN TOPIC REVIEWS Yoon-Nyun Kim MD, PhD Director of Electrophysiology, Division of Cardiovascular Medicine, Department of Internal Medicine Dongsan Medical center, Keimyung University of Korea School of Medicine, Daegu, Korea Ablation of supraventricular tachycardia ABSTRACT Radiofrequency catheter ablation therapy has been demonstrated to be successful in over 95% of patients with supraventricular tachycardia. Catheter ablation of atrioventricular nodal reentrant tachycardia is usually performed by slow pathway ablation. Two techniques have been used for successfully slow pathway ablation (an anatomic approach and an electrogram-guided approach). Usually, an accessory pathway is the target of ablation in patients with atrioventricular reentrant tachycardia. The best site for ablation of an accessory pathway is where it crosses the annulus. Localization and elimination of the accessory pathway can be achieved with detailed mapping. Key words: arrhythmias supraventricular tachycardia catheter ablation Received: February 19, 2011 Revision Received: May 16, 2011 Accepted: June 29, 2011 Correspondence: Yoon-Nyun Kim, MD, PhD, Director of Electrophysiology, Division of Cardiovascular Medicine, Department of Internal Medicine Dongsan Medical center, Keimyung University of Korea School of Medicine, 216 Dalsung rd Jung-ku, Daegu, , Republic of Korea Tel: , Fax: AVNRT (RFCA of AVNRT) 14 Journal of Cardiac Arrhythmia

17 Fast pathway Eustachian valve TOD Central fibrous body Tricuspid valve His MAIN TOPIC REVIEWS Oval fossa Inferior caval vein CS Slow pathway AB RV Inferior isthmus Central fibrous body Fast pathway Eustachian valve Tricuspid valve Fast pathway Central fibrous body TOD Oval fossa OF TV Inferior caval vein CS Slow pathway TOD IVC CS Slow pathway Inferior isthmus Figure 1. Koch slow conduction and the anatomic structure of the triangle as the location of the catheter for resection. AB; ablation catheter, His; His catheter, IVC; inferior vena cava, OF; oval fossa, RV; right ventricular catheter, TOD; tendon of Todaro (From Huang SK et al.: Catheter ablation of cardiac arrhythmias, 2nd ed. Philadelphia, Saunders, 2011.) VOL.12 NO.2 15

18 MAIN TOPIC REVIEWS ï AVRT 16 Journal of Cardiac Arrhythmia

19 n = 1,969 patients (1,146 m) Mean age years Patients Ebstein / APs 86 APs 1AP APs APs APs 8 1 5APs 5 2 6APs 1 0 MAIN TOPIC REVIEWS 2.2% n=52 Supero anterior 1.9% n=45 Superior 5.3% n=122 Supero paraseptal 2% n=46 Superior 12.2% n=282 Postero superior 2.7% n=63 Anterior 3.7% n=85 Right Septal Left 0.7% n=17 Posterior 22.9% n=530 Antero inferior Postero Inferior 3.9% n=91 3.5% n=81 Inferior 12.2% n=283 Infero paraseptal 12.5% n=290 Inferior 4.8% n= % n=218 Figure 2. 2,411 in 1,969 patients the location of pathways (From Ernst S, Ouyang F, Antz M, et al.: Catheter ablation of atrioventricular reentry. In Zipes DP, Jalife J. (eds): Cardiac Electrophysiology from Cell to Bedside, 4th ed. Philadelphia, WB Saunders, 2004, ) VOL.12 NO.2 17

20 MAIN TOPIC REVIEWS References 1. Jackman WM, Beckman KJ, McClelland JH, Wang X, Friday KJ, Roman CA, Moulton KP, Twidale N, Hazlitt HA, Prior MI, Oren J, Overholt ED, Lazzara R., Treatment of supraventricular tachycardia due to atrioventricular nodal reentry, by radiofrequency catheter ablation of slow-pathway conduction. N Engl J Med. 1992;327: Haissaguerre M, Gaita F, Fischer B, Commenges D, Montserrat P, d'ivernois C, Lemetayer P, Warin JF. Elimination of atrioventricular nodal reentrant tachycardia using discrete slow potentials to guide application of radiofrequency energy. Circulation. 1992;85: Efremidis M, Sideris A, Letsas KP, Alexanian IP, Pappas LK, Mihas CC, Manolatos D, Xydonas S, Gavrielatos G, Filippatos GS, Kardaras F. Potential-guided versus anatomic-guided approach for slow pathway ablation of the common type atrioventricular nodal reentry tachycardia: A randomized study. Acta Cardiol. 2009;64: Jentzer JH, Goyal R, Williamson BD, et al. Analysis of junctional ectopy during radiofrequency ablation of the slow pathway in patients with atrioventricular nodal reentrant tachycardia. Circulation. 1994;90: Arruda MS, McClelland JH, Wang X, et al. Development and validation of an ECG algorithm for identifying accessory pathway ablation site in wolff-parkinson-white syndrome. J Cardiovasc Electrophysiol. 1998;9: Plumb VJ: Catheter ablation of the accessory pathways of the Wolff-Parkinson-White syndrome and its variants. Prog Cardiovasc Dis. 1995; 37: Lesh MD, Van Hare GF, Scheinman MM, et al: Comparison of the retrograde and transseptal methods for ablation of left free wall accessory pathways. J Am Coll Cardiol. 1993; 22: Cappato R, Schluter M, Weiss C, et al: Radiofrequency current catheter ablation of accessory atrioventricular pathways in Ebstein's anomaly. Circulation. 1996; 94: Calkins H, Yong P, Miller JM, et al: Catheter ablation of accessory pathways, atrioventricular nodal reentrant tachycardia, and the atrioventricular junction: Final results of a prospective, multicenter clinical trial. The Atakr Multicenter Investigators Group. Circulation. 1999; 99: Morady F: Catheter ablation of supraventricular arrhythmias: State of the art. J Cardiovasc Electrophysiol. 2004; 15: Journal of Cardiac Arrhythmia

21 Fluoroscopic anatomy for supraventricular tachycardia ablation MAIN TOPIC REVIEWS Hui-Nam Pak, MD, PhD Division of Cardiology, Yonsei Cariovascular Center and Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea Fluoroscopic anatomy for supraventricular tachycardia ablation ABSTRACT Radiofrequency catheter ablation has become a major treatment strategy for tachyarrhythmia. Although developments of catheter technology and 3D mapping systems have made remarkable progress in the ablation success rate, fluoroscopy is still one of the most important equipments guiding the catheter to the target lesion. Especially, in patients who require focal ablation, catheter navigation is mostly dependent on the fluoroscopic anatomy. Here, I would like to review the cardiac anatomy from the view point of fluoroscopic images, especially during the ablation of supraventricular tachyarrhythmias. Key words: fluoroscopy anatomy catheter ablation supraventricular tachycardia Received: March 14, 2011 Accepted: June 29, 2011 Correspondence: Hui-Nam Pak, MD, PhD, Division of Cardiology, Yonsei Cariovascular Center and Cardiovascular Research Institute, Yonsei University College of Medicine, Korea 250 Seungsanno, Seodaemun-gu, Seoul, Republic of Korea Tel: , Fax: hnpak@yuhs.ac VOL.12 NO.2 19

22 MAIN TOPIC REVIEWS A B SAN SAN C LAO 35 D RAO 35 RSPV RIPV LSPV LIPV RIPV RSPV LSPV CS LAA MVA CS LAO 35 RAO 35 Figure 1. Fluoroscopic anatomy of right atrium (A and B) and left atrium (C and D). Sinoatrial node (SAN) exists on the junction between superior vena cava and right atrial appendage. Left atrium is connected with 4 pulmonary veins (PV) and left atrial appendage (LAA). Coronary sinus (CS) is located on the epicardial surface on posterolateral portion of left atrium. LIPV; left inferior PV, LSPV; left superior PV, RIPV; right inferior PV, RSPV; right superior PV 20 Journal of Cardiac Arrhythmia

23 MAIN TOPIC REVIEWS A B VOM VOM C MCV LAO 35 D MCV RAO 35 ABL ABL LAO 35 RAO 35 Figure 2. The relationship between coronary sinus (CS: A and B) and posteroseptum (C and D). Middle cardiac vein (MCV) branches at immediately proximal to CS ostium and vein of Marshall (VOM) separates the boundary of CS and great cardiac vein. Slow pathway of AV node exists on the lower 1/3 between CS ostium and His bundle recording area. VOL.12 NO.2 21

24 MAIN TOPIC REVIEWS A B C LAO 35 D RAO 35 LAO 35 RAO 35 Figure 3. The proper location of trans-septal puncture (A and B) and the relationship between esophagus and posterior left atrial wall (C and D). 22 Journal of Cardiac Arrhythmia

25 MAIN TOPIC REVIEWS Koch s triangle References 1. Ho SY, Anderson RH, Sanchez-Quintana D. Atrial structure and fibres: morphologic bases of atrial conduction. Cardiovasc Res. 2002;54: Corcoran SJ, Lawrence C, McGuire MA. The valve of Vieussens: an important cause of difficulty in advancing catheters into the cardiac veins. J Cardiovasc Electrophysiol. 1999;10: Choi JI, Pak HN, Park JH, Choi EJ, Kim SK, Kwak JJ, Jang JK, Hwang VOL.12 NO.2 23

26 MAIN TOPIC REVIEWS C, Kim YH. Clinical Significance of Complete Conduction Block of the Left Lateral Isthmus and Its Relationship with Anatomical Variation of the Vein of Marshall in Patients with Nonparoxysmal Atrial Fibrillation. J Cardiovasc Electrophysiol. 2009;20: Sun Y, Arruda M, Otomo K, Beckman K, Nakagawa H, Calame J, Po S, Spector P, Lustgarten D, Herring L, Lazzara R, Jackman W. Coronary sinus-ventricular accessory connections producing posteroseptal and left posterior accessory pathways: incidence and electrophysiological identification. Circulation. 2002;106: Hwang C, Peter CT, Chen PS. Radiofrequency ablation of accessory pathways guided by the location of the ligament of Marshall. J Cardiovasc Electrophysiol. 2003;14: Journal of Cardiac Arrhythmia

27 MAIN TOPIC REVIEWS Seil Oh, MD, PhD Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Hospital, Seoul, Korea Unusual type of supraventricular tachycardia ABSTRACT Most of supraventricular tachycardias (SVTs) are relatively easy to detect and get exact diagnosis with cardiac electrophysiological studies. In addition, catheter ablation has excellent outcome and high success rate of greater than 95%. However, it is still challenging for electrophysiologists in diagnosis and catheter ablation of unusual type of SVTs. Following topics are the scope of this review: accessory pathway with unusual electrophysiological or anatomical characteristics, and SVTs in congenital anomalies affecting catheter ablation procedures. Exact diagnosis and anatomical information would be the key components in successful ablation of unusual SVTs. Key words: supraventricular tachycardia accessory pathway congenital anomaly SVT Received: March 31, 2011 Accepted: June 29, 2011 Correspondence: Seil Oh, MD, PhD, FHRS, Department of Internal Medicine, Seoul National University College of Medicine Cardiac Electrophysiology Lab, Seoul National University Hospital Cardiovascular Center 101 Daehang-ro, Jongno-gu, Seoul , Korea Tel: , Fax: Mahaim VOL.12 NO.2 25

28 MAIN TOPIC REVIEWS Figure 1. Diagram of atriofascicular and atrioventricular pathway with Mahaim characteristics. AVN; atrioventricular node, BB; bundle branch, HB; His bundle, LBB; left bundle branch, RBB; right bundle branch 26 Journal of Cardiac Arrhythmia

29 I RA Pacing (500 ms) I SVT MAIN TOPIC REVIEWS II II III III V1 V1 HRA HRA HBE HBE ABL ABL RVA RVA 100 mm/s 100 mm/s Figure 2. Recording of accessory pathway potential (arrows) during atrial pacing at 500 ms and during tachycardia (SVT). Activation of the ventricle at the tricuspid annulus preceded that at the right ventricular apex, showing accessory pathway was atrioventricular fiber. ABL; Ablation catheter, HBE; His bundle, HRA; high right atrium, RVA; right ventricular apex V1 V2 V3 FV pathway WPW-AS Figure 3. Electrocardiograms of patients with fasciculoventricular pathway (FV pathway, 1-5) and WPW syndrome with anteroseptal accessory pathway (WPW-AS, 6-9). VOL.12 NO.2 27

30 MAIN TOPIC REVIEWS I II III HRA HBE 1,2 20 ms 20 ms HBE 3,4 RVA Figure 4. Electrogram showing short fixed HV interval (20 ms) and no change of preexcitation degree (open boxes with black dotted line) in a patient with fasciculoventricular pathway. ABL; Ablation catheter, HBE; His bundle, HRA; high right atrium, RVA; right ventricular apex Antegrade conduction Retrograde conduction Vein of Marshall Vein of Marshall CS ostium Great cardiac vein CS ostium Great cardiac vein Middle cardiac vein Posterior coronary vein Middle cardiac vein Posterior coronary vein Figure 5. Diagram of myocardial coat and accessory pathways of the coronary sinus. CS; coronary sinus 28 Journal of Cardiac Arrhythmia

31 Marshall MAIN TOPIC REVIEWS A I avf 100 ms B 200 ms V1 V6 Abl-d Abl-p HRA-p HRA-d HBE-p HBE-m HBE-d CS-5 CS-4 CS-3 CS-2 CS-1 Figure 6. Electrogram recording during ventricular pacing immediately before successful ablation. Arrow points to double potentials between the local V and A waves (A). Successful elimination of retrograde VA conduction (arrow) by radiofrequency energy application (B). ABL; Ablation catheter, CS; coronary sinus, HBE; His bundle, HRA; high right atrium VOL.12 NO.2 29

32 MAIN TOPIC REVIEWS A I avf V1 V6 HBEd HBEm HBEp RA 1,2 RA 3,4 RA 5,6 RA 7,8 RA 9, 10 ABLp ABLd RVA B I avf V1 V6 HBEd HBEp RA 1,2 RA 9, 10 ABLp ABLd RVA Figure 7. Electrograms in a patient with preexcitation and Ebstein anomaly before (A) and after catheter ablation (B). Electrogram recorded at ABL during sinus rhythm shows fractionated potentials (arrows) at atrioventricular groove (A). This site was not the exact location of accessory pathway. The fractionated potentials (arrows) during ventricular pacing were still observed even after successful ablation of the accessory pathway (B). ABL; Ablation catheter, HBE; His bundle, HRA; high right atrium, RA; right atrium, RVA; right ventricular apex 30 Journal of Cardiac Arrhythmia

33 SVT References 1. Anderson RH. The disposition and innervation of atrioventricular ring specialized tissue in rats and rabbits. J Anat. 1972;113: Anderson RH, Davies MJ, Becker AE. Atrioventricular ring specialized tissue in the normal heart. Eur J Cardiol. 1974;2: Yanni J, Boyett MR, Anderson RH, Dobrzynski H. The extent of the specialized atrioventricular ring tissues. Heart Rhythm. 2009;6: McClelland JH, Wang X, Beckman KJ, Hazlitt HA, Prior MI, Nakagawa H, Lazzara R, Jackman WM. Radiofrequency catheter ablation of right atriofascicular (mahaim) accessory pathways guided by accessory pathway activation potentials. Circulation. 1994;89: Choi YS, Lee MY, Kim HS, Sohn DW, Oh BH, Lee MM, Park YB, Seo JD, Lee YW, Choi YJ. Radiofrequency catheter ablation of a mahaim fiber at lateral tricuspid annulus. Korean Circ J. 1997;27: Abbott JA, Scheinman MM, Morady F, Shen EN, Miller R, Ruder MA, Eldar M, Seger JJ, Davis JC, Griffin JC, et al. Coexistent mahaim and kent accessory connections: Diagnostic and therapeutic implications. J Am Coll Cardiol. 1987;10: Sallee D, 3rd, Van Hare GF. Preexcitation secondary to fasciculoventricular pathways in children: A report of three cases. J Cardiovasc Electrophysiol. 1999;10: Sternick EB, Gerken LM, Vrandecic MO, Wellens HJ. Fasciculoventricular pathways: Clinical and electrophysiologic characteristics of a variant of preexcitation. J Cardiovasc Electrophysiol. 2003;14: Gallagher JJ, Smith WM, Kasell JH, Benson DW, Jr., Sterba R, Grant AO. Role of Mahaim fibers in cardiac arrhythmias in man. Circulation. 1981;64: MAIN TOPIC REVIEWS VOL.12 NO.2 31

34 MAIN TOPIC REVIEWS LAT 2-Mcp >134 points * RA11 AP RA Figure 8. Reconstructed 3D image using Cartomerge software (Biosense-Webster, Diamond Bar, CA) shows anterior view image excluding the left atrium, the right and left ventricles. This image clearly shows absence of right SVC and markedlydilated coronary sinus-persistent left SVC (asterisk). Ablation (dark red dots) for atrioventricular nodal reentrant tachycardia was successfully performed at the rim of the coronary sinus ostium just below the His-bundle potential area (blue dots). RA; right atrium 10. Hluchy J. Mahaim fibers: Electrophysiologic characteristics and radiofrequency ablation. Z Kardiol. 2000;89 Suppl 3: Kottkamp H, Hindricks G, Shenasa H, Chen X, Wichter T, Borggrefe M, Breithardt G. Variants of preexcitation--specialized atriofascicular pathways, nodofascicular pathways, and fasciculoventricular pathways: Electrophysiologic findings and target sites for radiofrequency catheter ablation. J Cardiovasc Electrophysiol. 1996;7: Oh S, Choi YS, Choi EK, Kim HS, Sohn DW, Oh BH, Lee MM, Park YB. Electrocardiographic characteristics of fasciculoventricular pathways. Pacing Clin Electrophysiol. 2005;28: Choi YS, Choi EK, Oh S. Typical atrioventricular nodal reentrant tachycardia in a patient with fasciculoventricular pathway. J Electrocardiol. 2007;40: Journal of Cardiac Arrhythmia 14. Oh S, Choi EK, Chung JW, Choi YS. Atypical atrioventricular nodal reentrant tachycardia in a patient with fasciculoventricular pathway. Heart Rhythm. 2006;3: Sun Y, Arruda M, Otomo K, Beckman K, Nakagawa H, Calame J, Po S, Spector P, Lustgarten D, Herring L, Lazzara R, Jackman W. Coronary sinus-ventricular accessory connections producing posteroseptal and left posterior accessory pathways: Incidence and electrophysiological identification. Circulation. 2002;106: Hwang C, Peter CT, Chen PS. Radiofrequency ablation of accessory pathways guided by the location of the ligament of marshall. J Cardiovasc Electrophysiol. 2003;14: Meiltz A, Weber R, Halimi F, Defaye P, Boveda S, Tavernier R, Kalusche D, Zimmermann M. Permanent form of junctional

35 reciprocating tachycardia in adults: Peculiar features and results of radiofrequency catheter ablation. Europace. 2006;8: Okishige K, Fisher JD, Goseki Y, Azegami K, Satoh T, Ohira H, Yamashita K, Satake S. Radiofrequency catheter ablation for AV nodal reentrant tachycardia associated with persistent left superior vena cava. Pacing Clin Electrophysiol. 1997;20: Pitzalis MV, Forleo C, Luzzi G, Anaclerio M, Barletta A, Di Biase M, Rizzon P. Successful ablation of atrioventricular nodal reentry tachycardia in a patient with persistent left superior vena cava. Cardiologia. 1998;43: MAIN TOPIC REVIEWS VOL.12 NO.2 33

36 ARTICLE REVIEW ipsc: Seil Oh, MD, PhD, FHRS Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Hospital, Seoul, Korea ipsc: New Paradigm in Diagnosis and Therapeutics Itzhaki I, Itzhaki I, Maizels L, Huber I, Zwi-Dantsis L, Caspi O, Winterstern A, Feldman O, Gepstein A, Arbel G, Hammerman H, Boulos M, Gepstein L. Nature. 2011;471: Received: April 17, 2011 Accepted: June 29, 2011 Correspondence: Seil Oh, MD, PhD, FHRS, Department of Internal Medicine, Seoul National University College of Medicine Cardiac Electrophysiology Lab, Seoul National University Hospital Cardiovascular Center 101 Daehang-ro, Jongno-gu, Seoul , Korea Tel: , Fax: References 1. Takahashi K, Yamanaka S. Induction of pluripotent stem cells from mouse embryonic and adult fibroblast cultures by defined factors. Cell. 2006;126: Journal of Cardiac Arrhythmia

37 2. Takahashi K, Tanabe K, Ohnuki M, Narita M, Ichisaka T, Tomoda K, Yamanaka S. Induction of pluripotent stem cells from adult human fibroblasts by defined factors. Cell. 2007;131: Itzhaki I, Maizels L, Huber I, Zwi-Dantsis L, Caspi O, Winterstern A, Feldman O, Gepstein A, Arbel G, Hammerman H, Boulos M, Gepstein L. Modelling the long qt syndrome with induced pluripotent stem cells. Nature. 2011;471: Moretti A, Bellin M, Welling A, Jung CB, Lam JT, Bott-Flugel L, Dorn T, Goedel A, Hohnke C, Hofmann F, Seyfarth M, Sinnecker D, Schomig A, Laugwitz KL. Patient-specific induced pluripotent stem-cell models for long-qt syndrome. N Engl J Med. 2010;363: ARTICLE REVIEW VOL.12 NO.2 35

38 ECG & EP CASES Yong-Seog Oh, MD, PhD Director of Electrophysiology, Division of Cardiovascular Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, College of Medicine, Seoul, Korea Infective endocarditis related to a pacemaker lead ABSTRACT Pacemaker lead infection is a serious complication. In most cases the pacemaker should be removed. A 52- year-old female patient with DDD pacemaker complained of fever. A blood culture revealed staphylococcus epidermidis and transthoracic echocardiography showed vegetation on the pacemaker lead. Vancomycin was administered; however, the patient s situation did not improve. Open heart surgery was performed via minithoracotomy. The vegetation and the pacemaker were removed and a tricuspid repair was performed. We report a case of infective endocarditis related to a pacemaker lead which was removed by minithoracotomy open heart surgery. Key words: infective endocarditis pacemaker Received: December 31, 2010 Accepted: June 29, 2011 Correspondence: Yong-Seog Oh, MD, PhD, Director of Electrophysiology, Division of Cardiovascular Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, College of Medicine, 505 Banpo-Dong Seocho-Ku, Seoul , Republic of Korea Tel: , Fax: oys@catholic.ac.kr 36 Journal of Cardiac Arrhythmia

39 ECG & EP CASES Figure 1. Transthoracic and transesophageal echocardiography showed large vegetation on the pacemaker lead. Figure 2. Vegetation on the pacemaker lead. VOL.12 NO.2 37

40 ECG & EP CASES References 1. Poole JE, Gleva MJ, Mela T, Chung MK, Uslan DZ, Borge R, Gottipaty V, Shinn T, Dan D, Feldman LA, Seide H, Winston SA, Gallagher JJ, Langberg JJ, Mitchell K, Holcomb R; REPLACE Registry Infestigators. Complication rates associated with pacemaker or implantable cardioverter-defibrillator replacements and upgrade procedures: results from the REPLACE registry. Circulation. 2010;122: Cacoub P, Leprince P, Nataf P, Hausfater P, Corent R, Wechsler B. Pacemaker infective endocarditis. Am J Cardiol : Journal of Cardiac Arrhythmia

41 Catheter ablation for AV nodal reentrant tachycardia in absent right and persistent left SVC ECG & EP CASES Seil Oh, MD, PhD, FHRS Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Hospital, Seoul, Korea Case Discussion Received: April 20, 2011 Accepted: June 29, 2011 Correspondence: Seil Oh, MD, PhD, FHRS, Department of Internal Medicine, Seoul National University College of Medicine Cardiac Electrophysiology Lab, Seoul National University Hospital Cardiovascular Center 101 Daehang-ro, Jongno-gu, Seoul , Korea Tel: , Fax: VOL.12 NO.2 39

42 ECG & EP CASES A B C LA LA LA * * RA RA RV RA RV IVC D E * * RA Figure (A), (B) and (C) are posterior, right anterior oblique, and anterior view images excluding the left ventricle, respectively. Asterisks indicate markedly dilated coronary sinus and persistent left superior vena cava. Image excluding both ventricles and the left atrium (D). Endoscopic view of the ablation site (E). Dark red dots indicate catheter ablation sites, and blue dots indicate area showing His bundle potential. References 1. Okishige K, Fisher JD, Goseki Y, Azegami K, Satoh T, Ohira H, Yamashita K, Satake S. Radiofrequency catheter ablation for av nodal reentrant tachycardia associated with persistent left superior vena cava. Pacing Clin Electrophysiol. 1997;20: Pitzalis MV, Forleo C, Luzzi G, Anaclerio M, Barletta A, Di Biase 40 Journal of Cardiac Arrhythmia M, Rizzon P. Successful ablation of atrioventricular nodal reentry tachycardia in a patient with persistent left superior vena cava. Cardiologia. 1998;43: Ernst S, Ouyang F, Linder C, Hertting K, Stahl F, Chun J, Hachiya H, Krumsdorf U, Antz M, Kuck KH. Modulation of the slow pathway in the presence of a persistent left superior caval vein using the novel magnetic navigation system niobe. Europace. 2004;6:10-14.

43 ECG & EP CASES Jin-Bae Kim MD, PhD Division of Cardiology. KyungHee University Medical Center, Seoul, Korea Catheter ablation of a right concealed accessory pathway in a hypertrophic cardiomyopathy patient with a left posteroseptal manifeste accessory pathway as an innocent bystander. ABSTRACT A 41-year-old man presented with a ventricular preexcitation syndrome and a hypertrophic cardiomyopathy. EP testing demonstrated that the manifeste bypass tract was an innocent bystander and another concealed bypass tract was utilized as retrograde conduction during atrioventricular reentry tachycardia. The accessory pathway could be localized at the right free wall and the left posteroseptal area. They were successfully abolished after subvalvular placement of the electrode catheter in the left ventricle. Successful RF ablation procedures provide an obvious risk reduction as a result of a lower frequency of atrial fibrillation and the eliminated risk of ventricular fibrillation due to rapid conduction via an accessory pathway. Key words: bypass tract catheter ablation hypertropic cardiomyopathy Received: April 25, 2011 Accepted: June 29, 2011 Correspondence: Jin-Bae Kim MD, PhD, Division of Cardiology. KyungHee University Medical Center, Seoul, Korea Tel: jinbbai@hanmir.com VOL.12 NO.2 41

44 ECG & EP CASES ORIGINAL I avr V1 V4 II avl V2 V5 III avf V3 V6 II Figure lead electrocardiogram on admission revealed ventricular preexcitation. 특성상(전방 지역 근무 군인) 증상 발현시 심전도를 측정하기 재발되지 않았다. 좌측 방실 전도 차단후 오른쪽 자유벽에 대 가 어려워, 전기 생리 검사를 진행하게 되었다. 한 잠복성 심실 심방 부전도로에 대한 Mapping을 진행하였 전기 생리 검사상 표준 12 유도 심전도상 관측되었던 으며 보다 정확한 위치를 찾기 위해 방실회귀성 빈맥을 유발 delta 파의 위치와는 달리 역방향 심실 심방간 전도가 오른 후에 진행하였다. 빈맥시 시행한 mapping결과 우측 삼첨판 쪽 자유벽의 부 전도로를 통하여 전달됨을 관찰할 수 있었고 륜 8시 방향에서 심실 심방 전도가 있음을 확인하였고 이에 심실 및 심방 조율로 유도된 방실 회귀 빈맥시에도 심실 심방 대한 전극도자 절제술을 진행하였다(Figure 3). 고주파 전 간 전도가 오른쪽 자유벽을 통한 전도가 관찰되었다. 따라서, 류 전달 1초 이내 심실 심방전도가 차단되었고 방실 해리 동성 리듬시 관찰할 수 있는 발현성 전 방향 방실 전도는 후중 (VA dissociation) 소견이 관찰되었으며 같은 위치에 2차례 격 위치이나 환자의 빈맥과는 상관이 없는 방관자 (innocent 더 고주파 절제술을 진행하였고 절제술후 30분간 관찰하였 bystander)임을 확인할 수 있었다. 전극 도자 절제술은 우 으나 delta파나 심실심방 부전도에 의한 전도의 재발 없어 선 추후 환자의 예후를 고려하여 전 방향 방실전도를 하고 있 시술을 종료하였다. 환자는 시술후 현재까지 delta파의 재발 는 발현성 부전도로를 먼저 시행하였다. 표준 12 유도로 우 이나 심계항진의 재발 없이 국군 병원에서 추적 관찰 중이다. 측 후 중격에서의 방실 전도가 의심되어 하부대정맥을 통한 방법으로 동성 리듬에서 후중격의 부전도로의 도자 절제술을 고찰 시행하였다(Figure 2). 전극 도자 절제술 시행중 쉽게 delta 42 파가 없어지는 방실부전도로의 차단을 관찰할수 있었으나 지 본 환자는 비후성 심근 병증과 더불어 표준 12유도 심전도 속적으로 재발이 있어 대동맥을 경유하는 방법으로 좌심실에 상 심실 조기 흥분 증후군을 동반한 환자로 최근 수개월동안 서 후중격의 부전도로에 대한 전극도자 절제술을 시행하였으 심계 항진이 있어 빈맥성 부정맥의 발현 여부와 급사의 위험 며 최초 절제술시 2.6초만에 delta파가 차단되어 이후에는 도 평가 위해 전기 생리 검사가 필요하였던 경우였다. 비후성 Journal of Cardiac Arrhythmia

45 ECG & EP CASES I avf V1 HRAd HRAp CSp CSd Hisd Hisp Abld Ablp RV Figure 2. Intracardiac electrogram during radio-frequency ablation of manifeste bypass tract. Radio-frequency ablation was performed via transaortic approach. Red arrow indicate delta wave disappeared after 2.6 seconds of RF application I avf V1 Aclp Abld HRAp HRAd CSp CSd Hisp Hisd RV Figure 3. Atrioventricular reentrant tachycardia was terminated immediately after radio-frequency application. Red arrow indicate the start point of RF application VOL.12 NO.2 43

46 ECG & EP CASES Figure 4. The catheter position of successful ablation site. White arrow indicate successful ablation site of left poteroseptal bypass tract and yellow arrow indicate right free wall bypass tract. References 1. Josephson ME. Clinical Cardiac Electrophysiology: Technique and interpretation, 4th ed, PA: Lippincott Williams & Wikins, McKenna WJ, Kleinebenne A. Arrhythmias in hypertrophic cardiomyopathy; Significance and therapeutic consequences. Herz. 1985;10(2): Journal of Cardiac Arrhythmia

47 ECG & EP CASES Young-Keun On, MD, PhD Division of Cardiology, Department of Medicine Cardiac & Vascular Center, Samsung Medical Center Sungkyunkwan University School of Medicine, Seoul, Korea A case of paroxysmal antidromic atrioventricular reentrant tachycardia with AF ABSTRACT In the Wolff-Parkinson-White (WPW) syndrome, atrioventricular (AV) conduction occurs through an AV bypass tract, which results in earlier activation (preexcitation) of the ventricles. Antidromic atrioventricular reentrant tachycardia (AVRT) is characterized by a wide QRS complex and ventricular rates of up to 250 beats/min. The width of the preexcited QRS complex and the amplitude of the ST-T wave segment usually obscure the retrograde P wave on the surface ECG. The rhythm of preexcited atrial fibrillation (AF) is exceptionally irregular, and can be associated with very rapid ventricular responses caused by the nondecremental anterograde AV conduction over the bypass tract. A shortest preexcited RR interval of less than 250 milliseconds during sustained AF is a very sensitive marker of the risk of VF in WPW syndrome. Catheter ablation is considered first-line therapy for patients with WPW syndrome. Key words: Wolff-Parkinson-White (WPW) syndrome antidromic atrioventricular reentrant tachycardia (AVRT) catheter ablation Received: April 1, 2011 Accepted: June 29, 2011 Correspondence: Young-Keun On, MD, PhD, Division of Cardiology, Department of Medicine Cardiac & Vascular Center, Samsung Medical Center Sungkyunkwan University School of Medicine, 50 Irwon-dong Gangnam-gu, Seoul, Korea, Tel: , Fax: yk.on@samsung.com VOL.12 NO.2 45

48 ECG & EP CASES I avr V1 V4 II avl V2 V5 III avf V3 V6 II Figure 1. Surface electrocardiogram showed the wide QRS tachycardia with irregular heart rhythm, which revealed positive QRS in the precordial and inferior leads. 46 Journal of Cardiac Arrhythmia

49 avr V1 V4 II avl V2 V5 III avf V3 V6 ECG & EP CASES I II Figure 2. Surface electrocardiogram showed the normal sinus rhythm with pre-excitation, which revealed positive QRS in the precordial and inferior leads. I avr V1 V4 II avl V2 V5 III avf V3 V6 II Figure 3. Surface electrocardiogram during tachycardia showed the wide QRS tachycardia with positive QRS in the precordial and inferior leads. VOL.12 NO.2 47

50 ECG & EP CASES I avf 200 ms V1 V 6 HRA dist HRA prox HIS dist HIS prox CS 9,10 CS 7,8 CS 5,6 CS 3,4 CS 1,2 RVa dist RVa prox stm 2 4:04:52 PM 4:04:53 PM 4:04:54 PM Figure 4. Intracardial electrogram showed the atrial fibrillation. I 200 ms avf V1 V 6 HRA dist HRA prox HIS dist HIS prox CS 9, msec 212 BPM CS 7,8 CS 5,6 CS 3,4 CS 1,2 RVa dist RVa prox stm 2 4:11:44 PM 4:11:45 PM 4:11:46 PM Figure 5. Intracardial electrogram showed the atrioventricular reentrant tachycardia with antegrade conduction through the left anterolateral accessory pathway. 48 Journal of Cardiac Arrhythmia

51 ECG & EP CASES RAO LAO Figure 6. Fluoroscopy showed that the radiofrequency catheter was located at the ateral site of the mitral annulus. References 1. Morady F. Catheter ablation of supraventricular arrhythmias: State of the Art. Pacing Clin Electrophysiol. 2004;27: Scheinman M, Calkins H, Gillette P, et al: NASPE policy statement on catheter ablation: personnel, policy, procedures, and therapeutic recommendations. Pacing Clin Electrophysiol. 2003;26: Zipes DP, Jalife J. Cardiac Electrophysiology, From cell to bedside, 5th ed, Saunders, VOL.12 NO.2 49

52 ECG & EP CASES Jun Kim, MD Department of Internal Medicine, Pusan National University School of Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea Catheter ablation of atrioventricular bypass tract during atrial fibrillation ABSTRACT Catheter ablation is a treatment of choice in symptomatic patients with ventricular preexcitation. Mapping and ablation is usually done during sinus rhythm, ventricular pacing or induced atrioventricular reentrant tachycardia. Recurrent atrial fibrillation may complicate the mapping and ablation. Here we report a successful catheter ablation of a manifest left free wall bypass tract during atrial fibrillation guided by intracardiac bipolar and unipolar electrograms in a 23-year-old man. Key words: Wolff-Parkinson-White syndrome atrial fibrillation ablation Case Received: March 22, 2011 Accepted: June 29, 2011 Correspondence: Jun Kim, MD, Cardiovascular center, Pusan National University Yangsan Hospital, Geum-o Street, Yangsan, Republic of Korea ( ) Tel: , Fax: mdjunkim@yahoo.co.kr 50 Journal of Cardiac Arrhythmia

53 I A 500 ms B ECG & EP CASES II III 214 msec 279 BRP AVR AVL AVF V1 V 2 V 3 V 4 V 5 V 6 Figure 1. A 12-lead electrocardiogram during sinus rhythm (A) and atrial fibrillation (B). I 500 ms II III V1 HRA HIS 7,8 HIS 5,6 HIS 3,4 HIS 1,2 CS 9,10 CS 7,8 CS 5,6 CS 3,4 CS 1,2 RVA stm 2 S2 Figure 2. Surface electrocardiogram with intracardiac electrograms was displayed from top to bottom. Immediately after direct current cardioversion, there is a sinus beat with ventricular preexcitation followed by ventricular premature complex with retrograde concentric activation. After another sinus beat with ventricular preexcitation, atrial ectopic beat initiates atrial fibrillation. VOL.12 NO.2 51

54 ECG & EP CASES Discussion A B I 200 ms II III V 1 Abl p Abl d HRA HBE CS Abl Abl uni C 25 ms RVA I II III V 1 Ablp Abld 1000 ms Figure 3. Surface electrocardiogram with bipolar and unipolar electrograms recorded from the mapping catheter at the successful ablation site. In the unipolar electrogram, there is QS pattern and onset of local ventricular activation preceding the onset of delta wave by 25 ms (A). Fluoroscopic view of catheter position in the anteroposterior view (B). An application of radiofrequency energy abolished delta wave in 4 seconds (C). 52 Journal of Cardiac Arrhythmia

55 References 1.Blomström-Lundqvist C, Scheinman MM, Aliot EM, Alpert JS, Calkins H, Camm AJ,Campbell WB, Haines DE, Kuck KH, Lerman BB, Miller DD, Shaeffer CW, Stevenson WG,Tomaselli GF, Antman EM, Smith SC Jr, Alpert JS, Faxon DP, Fuster V, Gibbons RJ, Gregoratos G, Hiratzka LF, Hunt SA, Jacobs AK, Russell RO Jr, Priori SG, BlancJJ, Budaj A, Burgos EF, Cowie M, Deckers JW, Garcia MA, Klein WW, Lekakis J,Lindahl B, Mazzotta G, Morais JC, Oto A, Smiseth O, Trappe HJ; European Societyof Cardiology Committee, NASPE-Heart Rhythm Society.ACC/AHA/ESC guidelines for the management of patients with supraventriculararrhythmias-- executive summary. a report of the American college ofcardiology/american heart association task force on practice guidelines and theeuropean society of cardiology committee for practice guidelines (writingcommittee to develop guidelines for the management of patients withsupraventricular arrhythmias) developed in collaboration with NASPE-Heart Rhythm Society. J Am Coll Cardiol. 2003;42: Haïssaguerre M, Fischer B, Warin JF, Dartigues JF, Lemétayer P, Egloff P. Electrogram patterns predictive of successful radiofrequency catheter ablation of accessory pathways. Pacing Clin Electrophysiol. 1992;15(11 Pt 2): Grimm W, Miller J, Josephson ME.Successful and unsuccessful sites of radiofrequency catheter ablation of accessory atrioventricular connections. Am Heart J. 1994;12: Hindricks G, Kottkamp H, Chen X, Willems S, Haverkamp W, Shenasa M, Breithardt G, Borggrefe M. Localization and radiofrequency catheter ablation of left-sidedaccessory pathways during atrial fibrillation. Feasibility and electrogramcriteria for identification of appropriate target sites. J Am Coll Cardiol. 1995;25: Haïssaguerre M, Fischer B, Labbé T, Lemétayer P, Montserrat P, d'ivernois C,Dartigues JF, Warin JF.Frequency of recurrent atrial fibrillation after catheter ablation of overtaccessory pathways. Am J Cardiol. 1992;69: Brembilla-Perrot B, Popescu I, Huttin O, Zinzius PY, Muresan L, Jarmouni S, Nossier I, Schwartz J, Sellal JM, Beurrier D, Andronache M, de Chillou C, Selton O, Louis P, Terrier de la Chaise A. Risk of atrial fibrillation according to the initial presentation of apreexcitation syndrome. Int J Cardiol Jan 14. [Epub ahead of print] ECG & EP CASES VOL.12 NO.2 53

56 ECG & EP CASES Bo-Young Joung, MD, PhD Division of Cardiology, Yonsei University College of Medicine, Seoul, Korea ECG findings to diagnose supraventricular tachycardia ABSTRACT Often, the P waves of AV nodal reentry are seen just prior to or just after the end of the QRS and cause a subtle alteration in the QRS complex that results in a pseudo-s or pseudo-r. The AV nodal reentry begins abruptly, usually following a premature atrial complex that conducts with a prolonged PR interval. The retrograde P wave of AV reciprocating tachycardia occurs after completion of the QRS complex, in the ST segment, or early in the T wave. The presence of an ipsilateral bundle branch block can facilitate reentry and cause the prolonging of the tachycardia cycle length. Finally, vagal maneuvers or an adenosine injection could help in case of differential diagnosis of regular narrow QRS tachycardias. Key words: AV nodal reentry AV reciprocating tachycardia ECG Received: March 15, 2011 Accepted: June 29, 2011 Correspondence: Bo-Young Joung, MD, PhD, Yonsei University College of Medicine, 250 Seungsanno, Seodaemun-gu, Seoul, Republic of Korea Tel: , Fax: cby6908@yuhs.ac 54 Journal of Cardiac Arrhythmia

57 A III ECG & EP CASES V5 B III V5 Figure 1. Paroxysmal AV nodal reentrant tachycardia initiated by an atrial premature beat (A). After 4 sinus beats, an atrial premature beat ( ) is conducted with a longer PR and initiates reentry in the AV junction; retrograde P waves ( ) are seen right at the end of the subsequent QRS complexes (slow-fast tachycardia) (B). After the 5th beat, the retrograde P wave disappears ( ) (B). VOL.12 NO.2 55

58 ECG & EP CASES A C I avr V1 V4 V4 avr I II avl V2 V1 V5 avl V5 II III avf V3 V2 V6 avf V6 III V3 B II Figure 2. AV reciprocating tachycardia with a left lateral accessory pathway. Wide QRS tachycardia with LBBB (A). The transition from wide to narrow QRS tachycardia (B). Narrow QRS tachycardia (C). The tachycardia cycle lengths of LBBB and narrow QRS tachycardia were 320 and 280 ms, respectively. A B avr V4 I I avr V1 V1 avl V5 II V2 V2 V6 V3 ❶ V1 V5 II avf III C avl V4 III avf V3 V6 ❷ ❸ ❸ ❹ Figure 3. Atrial tachycardia with aberrant conduction. Narrow QRS tachycardia (A). Wide QRS tachycardia with RBBB (B). Atrial tachycardia (C). Note the different morphologies of QRS according to the degree of aberration. 56 Journal of Cardiac Arrhythmia

59 ECG & EP CASES References 1. Olgin JE, Zipes D. Specific arrhythmias: Diagnosis and treatment. In Libby P, Bonow R, Mann D, Zipes D, eds: Braunwald s Heart Disease. eighth edition. Philadelphia: Saunders Elsevier, 2010, pp VOL.12 NO.2 57

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68 Korean Heart Rhythm Society Room 805, Masters Tower #553, Dohwa-dong, Mapo-gu, Seoul , Korea Phone Fax