Original Articles Korean Circulation J 2002;32 3 : 아데노신투여로방실결절내이중전도로의진단시 관찰되는방실차단의의의 한승환 1 김영훈 1 이현수 1 이호준 1 신성희 1 박창규 1 서홍석 1 심완주 1 오동주 1 노영무

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1 Original Articles Korean Circulation J 2002;323: 아데노신투여로방실결절내이중전도로의진단시 관찰되는방실차단의의의 한승환 1 김영훈 1 이현수 1 이호준 1 신성희 1 박창규 1 서홍석 1 심완주 1 오동주 1 노영무 1 황교승 2 Significance of Atrio-Ventricular Block Following Atrio-His Jump in the Diagnosis of Dual Atrioventricular Nodal Physiology with Adenosine Infusion Seung Hwan Han, MD 1, Young-Hoon Kim, MD 1, Hyun Soo Lee, MT 1, Hojun Rhee, MD 1, Sung Hee Shin, MD 1, Chang Gyu Park, MD 1, Hong Seog Seo, MD 1, Wan Joo Shim, MD 1, Dong Joo Oh, MD 1, Young Moo Ro, MD 1 and Gyo Seung Hwang, MD 2 1 Department of Internal Medicine, Korea University, Seoul, 2 Department of Internal Medicine, Ajou University, Suwon, Korea ABSTRACT Background and ObjectivesAtrioventricular block AVB is frequently seen following atrio-his AH interval lengthening after adenosine injection during sinus rhythm when both the fast and slow pathways are blocked in patients with dual atrioventricular nodal physiology DAVNP. However, the condition also occurs in patients without DAVNP. Therefore, an AH jump may not indicate DAVNP if AVB is accompanied. The goal of this study was to use a low dose 69 mg of adenosine to determine whether an AH jump truly represents DAVNP when the presence or absence of AVB following the AH jump is taken into consideration. Subjects and MethodsThis study included 78 patients malefemale4731, age years, DAVNP group, n46, control group, n32. Adenosine 69 mg was administered intravenously during sinus rhythm. The inclusion criteria of DAVNP were either induced AVNRT n37common type, n35, uncommon, n2 or identification of AH jump n9 during elctrophysiology study EPS. The control group consisted of patients without evidence of DAVNP and noninducible AVNRT on EPS. In all subjects, the electrophysiologic parameters of the AV nodal properties were tested. ResultsIn the DAVNP group, intravenous adenosine during sinus rhythm resulted in an AH jump without AVB 8/46, 17.4%, an AH jump followed by AVB 9/46, 19.6%, an AH jump accompanied by induced AVNRT 1/46, 2.1%, or no significant changes in the AH interval 28/46, 60.9%. In the control group, none of the subjects showed an AH jump without AVB, however an AH jump with subsequent AVB was observed in 4 of 32 subjects 12.5%. If the finding of an AH jump without AVB alone was considered as a positive criteria of DAVNP, its specificity 87.5% to 100% and positive predictive value 81.8% to 100% increased compared to the criteria defined by an AH jump regardless of the presence or absence of AVB, however, its sensitivity decreased from 39.1% to 241

2 19.6%. ConclusionAH jump induced by adenosine injection may not indicate DAVNP if AVB follows. Korean Circulation J 2002;323: KEY WORDSTachycardia, atrioventricular nodal reentryadenosineheart block. 서론 242 대상및방법 대상 Table 1. Subjects of study group n78, age years, MF4731 Dual AV nodal physiology group n46 Inducible AVNRT n37 common35, uncommon2 Not inducible AVNRT but, AH jump on atrial extrastimuli n9 Control group n32 AVatrio-ventricular, AVNRTatrioventricular nodal reentrant tachy-cardia, AHatrio-his Korean Circulation J 2002;323:

3 방법 통계분석 결과 동율동에서아데노신정주후의반응양상 243

4 Fig. 1. Response after adenosine injection during sinus rhythm in group with dual AV nodal physiology and control. AHatrio-his, AVBatrioventricular block, AVNRT atrioventricular nodal reentrant tachycardia, AVatrioventricular. 동율동하에서아데노신정주후보이는방실차단을동반하는 AH jump의의의 AH jump를보인이중전도로군에서방실차단유무에따른전기생리적지표의차이 Fig. 2. AH jump with AV block after adenosine injection during sinus rhythm. AHatrio-his, AVatrioventricular. 244 Korean Circulation J 2002;323:

5 Fig. 3. AH atrio-his jump without AV atrioventricular block after adenosine injection during sinus rhythm. Fig. 4. Wenckebach AV atrioventricular block after adenosine injection during sinus rhythm. AVNRT 환자에서완속전도로완전절제후동율동에서아데노신정주후양상 245

6 고 Fig. 5. Sensitivity, specificity, positive predictive value, and negative predictive valuecomparison between two difinition of dual AV atrioventricular nodal physiology according to presence or absence of AV block following AH atrio-his jump. 찰 Table 2. Comparison of electrical parameters between AH jump without AV block patients and AH jump with AV block patients in dual AV nodal physiology group Unitmsec AH jump without AV block n8 AH jump with AV block n9 SCL NS AH interval NS HV interval NS QRS duration NS TCL NS AH interval during tachycardia NS HV interval during tachycardia NS Fast pathway ERP NS Slow pathway ERP NS AERP NS AVBCL p0.05 Maximal AH interval after adenosine injection NS Values are expressed as meansd Mann-Whitney U test. AHatrio-his, AVatrioventricular, SCLsinus cycle length, NSnot significant, HVhis-ventricular, TCLtachycardia cycle length, ERPeffective refractory period, AERP atrial effective refractory period, AVBCLatrioventricular block cycle length p 246 Korean Circulation J 2002;323:

7 Fig. 6. Change in AH interval with adenosine injection before and after slow pathway elimination in AVNRT patient. AHatrio-his, AVatrioventricular, AVNRTatrioventricular nodal reentrant tachycardia. Fig. 7. Pattern after adenosine injection before and after slow pathway elimination in AVNRT patient. AVatrioventricular, AHatrio-his, AVNRTatrioventricular nodal reentrant tachycardia. 247

8 248 본연구의제한점 본연구의임상적인의미 요약 배경및목적 : Korean Circulation J 2002;323:

9 방법 : 결과 : 결론 : 중심단어 REFERENCES 1) Belhassen B, Fish R, Glikson M, Glick A, Eldar M, Laniado S, Viskin S. Noninvasive diagnosis of dual AV node physiology in patients with AV nodal reentrant tachycardia by administration of adenosine-5 -triphosphate during sinus rhythm. Circulation ) Fishberger SB, Mehta D, Rossi AF, Langan MN, Marx SO, Gomes JA. Variable effects of adenosine on retrograde conduction in patients with atrioventricular nodal reentry tachycardia. Pacing Clin Electrophysiol ) Mewis C, Kuhlkamp V, Bosch RF, Seipel L. Variable responsiveness of anterograde and retrograde fast pathway conduction to adenosine in patients with typical AV-nodal reentry tachycardia. Int J Cardiol ) Dierkes S, Vester EG, Dobran LJ, Perings C, Strauer BE. Adenosine in the noninvasive diagnosis of dual AV nodal conduction use as a follow-up parameter after slow pathway ablation in AVNRT. Acta Cardiol ) Belhassen B, Fish R, Eldar M, Glick A, Glikson M, Viskin S. Simplified ATP test for noninvasive diagnosis of dual AV nodal physiology and assessment of results of slow pathway ablation in patients with AV nodal reentrant tachycardia. J Cardiovasc Electrophysiol ) Tebbenjohanns J, Niehaus M, Korte T, Drexler H. Noninvasive diagnosis in patients with undocumented tachycardias value of the adenosine test to predict AV nodal reentrant tachycardia. J Cardiovasc Electrophysiol ) Belhassen B, Fish R, Viskin S, Glick A, Glikson M, Eldar M. Adenosine-5 -triphosphate test for the noninvasive diagnosis of concealed accessory pathway. J Am Coll Cardiol ) Viskin S, Fish R, Glick A, Glikson M, Eldar M, Belhassen B. The adenosine triphosphate test a bedside diagnostic tool for identifying the mechanism of supraventricular tachycardia in patients with palpitations. J Am Coll Cardiol ) Sharma AD, Klein GJ. Comparative quantitative electrophysiologic effects of adenosine triphosphate on the sinus node and atrioventricular node. Am J Cardiol ) Calkins H, Yong P, Miller JM, Olshansky B, Carlson M, Saul JP, Huang SK, Liem LB, Klein LS, Moser SA, Bloch DA, Gillette P, Prystowsky E. Catherter ablation of accessory pathways, atrioventricular nodal reentrant tacycardia, and the atrioventricular junction final results of a prospective, multicenter clinical trial. Circulation ) Kalbfleisch SJ, Calkins H, Langberg JJ, el-atassi R, Leon A, Borganelli M, Morady F. Comparison of the cost of radiofre-quency catherter modification of the atrioventricular node and medical therapy for drug refractory atrioventricular node reentrant tachycardia. J Am Coll Cardiol ) Belhassen B, Pelleg A, Shoshani D, Geva B, Laniado S. Electrophysiologic effects of adenosine-5 -triphosphate on atrioventricular reentrant tachycardia. Circulation ) di Marco JP, Sellers TD, Berne RM, West GA, Belardinelli L. Adenosine electrophysiologic effects and therapeutic use for terminating paroxysmal supraventricular ta- 249

10 chycardia. Circulation ) Lerman BB, Belardinelli L. Cardiac electrophysiology of adenosine. Circulation ) Parker RB, McCollam PL. Adenosine in the episodic treatment of paroxysmal supraventricular tachycardia. Clin Pharm ) Lai WT, Lee CS, Wu JC, Sheu SH, Wu SN. Effects of verapamil, propranolol, and procainamide on adenosineinduced negative dromotropism in human beings. Am Heart J ) Wang D, Shryock JC, Belardinelli L. Cellular basis for the negative dromotropic effect of adenosine on rabbit single atrioven-tricular nodal cells. Circ Res ) Xu J, Tong H, Wang L, Hurt CM, Pelleg A. Endogenous adenosine, A1 adenosine receptor, and pertussis toxin sensitive guanine nucleotide binding protein mediate hypoxia induced AV nodal conduction block in guinea pig heart in vivo. Cardiovasc Res ) Favale S, di Biase M, Rizzo U, Belardinelli L, Rizzon P. Effect of adenosine and adenosine-5 -triphosphate on atrioventricular conduction in patients. J Am Coll Cardiol ) Shen WK, Kurachi Y. Mechanisms of adenosinemediated action on cellular and clinical cardiac electrophysiology. Mayo Clin Proc ) Domanovits H, Laske H, Stark G, Sterz F, Schmidinger H, Schreiber W, Mullner M, Laggner AN. Adenosine for the management of patients with tachycardias a new protocol. Eur Heart J ) di Marco JP, Sellers TD, Lerman BB, Greenberg ML, Berne RM, Belardinelli L. Diagnostic and therapeutic use of adenosine in patients with supraventricular tachyarrhythmias. J Am Coll Cardiol ) Cohen TJ, Tucker KJ, Abbott JA, Botvinick EH, Foster E, Schiller NB, O Connell JW, Scheinman MM. Usefulness of adenosine in augmenting ventricular preexicitation for noninvasive localization of accessory pathways. Am J Cardiol ) Garratt CJ, Antoniou A, Griffith MJ, Ward DE, Camm AJ. Use of intravenous adenosine in sinus rhythm as a diagnostic test for latent preexicitation. Am J Cardiol ) Morgan-Hughes NJ, Griffith MJ, McComb JM. Intravenous adenosine reveals intermittent preexcitation by direct and indirect effects on accessory pathway conduction. Pacing Clin Electrophysiol ) Keim S, Curtis AB, Belardinelli L, Epstein ML, Staples ED, Lerman BB. Adenosine-induced atrioventricular block a rapid and reliable method to assess surgical and radiofrequency catheter ablation of accessory atrioventricular pathways. J Am Coll Cardiol ) Walker KW, Silka MJ, Haupt D, Kron J, McAnulty JH, Halperin BD. Use of adenosine to identify patients at risk for recurrence of accessory pathway conduction after initially successful radiofrequency catheter ablation. Pacing Clin Electrophysiol ) Sharma AD, Klein GJ, Yee R. Intravenous adenosine triphosphate during wide QRS comples tachycardia safety, therapeutic efficacy, and diagnostic utility. Am J Med ) Griffith MJ, Linker NJ, Ward DE, Camm AJ. Adenosine in the diagnosis of broad complex tachycardia. Lancet ) Camm AJ, Garratt CJ. Adenosine and supraventricular tachycardia. N Engl J Med Korean Circulation J 2002;323:

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ºÎÁ¤¸ÆV10N³»Áö A case of atrioventricular dissociation with interference ABSTRACT Interference dissociation is one of the most interesting arrhythmias. Once thought to be a rare arrhythmia, it is now considered a very