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Surgical management of right atrial tachycardia
ABSTRACTS
WEDNESDAY, APRIL 28, 1982 AM SUPRA VENlRfCULAR TACH YCA RDIA AND PREEXCITA TtDN SYNDROMES 10:30- 12:oo DUAL A-V NODAL PATHWAYS AND ATRIAL FIBRILLATION. Pedro Brugada, MD; Denis Roy; MD; James Weiss, MD; Willem R. Dassen, PhD; Frits W. Bir, MD; Hein 3.5. Wellens, MD, FACC. Department of Cardiology, University of Limburg, Annadal Hospital, Maastricht, The Netherlands. The determinants of the ventricular rate during atria1 fibrillation (AF) in patients (pts) with dual A-V nodal pathways ( DAVNP ) are not known. In 11 consecutive pts with DAVNP having AF lasting longer than I min initiated during programmed electrical stimulation of the heart, the shortest R-R interval (ShRR) and mean ventricular cycle length (MVCL) during AF were measured. These values were compared with the effective refractory period (ERP) and functional (FRP) RP of the fast (f) and the slow (s) AVN P using at least 2 different basic cycle lengths for their measurement. The shortest cycle length with l-to-l A-V conduction was also determined during incremental atria1 pacing. A group of 8 pts with normal A-V nodal function and no evidence for DAVNP served as control. No pts had an accessory pathway. Results: The ShRR during AF ( 350260 ms )was related to the shortest CL with l-to-l A-V conduction ( 358+50 ms ) ( r=+U.95 ), and not to the ERP or FRP of the f 2nd s AVN P. The MVCL during AF ( 486~114 ms ) was not related to any of these variables in pts with DAVNP. The same was found for the control group. There were no differences between the two groups in ShRR and MVCL during AF. CONCLUSIONS: I) The ShRR during AF in pts with or without DAVNP can be predicted from the shortest CL with l-to-l A-V conduction . 2) Retrograde concealed penetration in the f AVNP does not seem to play a role in the MVCL in pts with DAVNP and AF.
ONE-TO-ONE AlRIOVENTRICULAR CONDUCTION DURING ATRIAL
PACING AT RATESOF 300/MIN IN ABSENCE OF WOLFF-PARKINSONWHITEsYNL%UME Federico Moleiro, MD; Agustin Castellanos, MD, FACC; ‘Ivan J. Mendoza. MD: Victor wdina-Ravell. MD; Robert J. Myerburg, MD, FACC,‘Univ. Central de Vene&ela,Caracas, Venezuela and the University of Miami School of Medicine, Miami, Florida. One- to-one atrioventricular
(AV) conduction during atria1 pacing at rates of 300/min has not been reported in absence of Wolff-Parkinson-White syndrome. ‘Ihis exceptional finding was demonstrated in three patients with short PR (and AH)intervals and narrow QRScomplexes. The AH intervals during atria1 pacing at 300/min increased (minimally) to 85, 90 and 90 msec respectively, Case 1 (with normal HV intervals) had fast (290-270/min) ventricular rates during atria1 fibrillation which were decreased to around lOO/min with intravenous verapamil. In Case 2 (also with normal HV intervals) atria1 pacing at rates of 300/min occurred only after atropine administration. In Case 3 the HV intervals were short (25 msec) during sinus rhythm and atria1 pacing at rates of 300/min. However, in echo beats, or when the His bundle was paced, the HV and St-V intervals became normal (40 msec). ‘Ihis patient had episodes of atria1 flutter with 1:l AV conduction which did not respond to verapamil, but to cardioversion. Although the three patients had as “connnondenominators” the short PR intervals and narrow QRScomplexes, they had different electrophysiological mechanisms: spontaneous (Case l), or pharmacological (Case Z), enhanced AV nodal conduction, and atrio (“distal”) His bundle tract (Case 3). The distinct electrophysiological mechanisms may explain the different responses to therapy.
994
March 1982
The American Journal of CARDIOLOGY
EFFECT OF BUNDLE BRANCH BLOCK ON VENTRICULOATRIAL INTERVALS DURING RECIPROCATING TACRYCARDIA IN PATIENTS WITH ACCESSORY ATRIOVENTRICIJLAR PATHWAYS. Charles R. Kerr, MD, John J. Gallagher, MD, FACC, Lawrence D. German, MD. Duke University Medical Center, Durham, N.C. During reciprocating tachycardia in patients with accessory atrioventricular pathways, changes in ventriculoatrial (VA) intervals with bundle branch block (BBB) have been used to localize the site of the pathway and to prove its participation in the tachycardia. We present the changes seen during BBB in 93 patients with single atrioventricular pathways who subsequently had the site of their pathways proven by intraoperative mapping and surgical interruption. In 60 patients with left or right freewall pathways the VA intervals prolonged by 61f9 msec (p
SURGICAL MANAGEMENT OF RIGHT ATRIAL TACHYCAFDIA Paul A. Russell, FRACP, David C. Johnson, FHACS, Alan R. Denniss, MB, David A. Richards, FRACP, John B. Uther, MD, FRACP, Westmead Centre, Sydney, Australia. There have been only two reported cases of excision of an atria1 focus responsible for tachycardia. we present five patients (aged 22-42), with atria1 tachycardia, refractory to medical therapy, who underwent epicardial mapping and excision of the atria1 focus. Pre-operative endocardial electrophysiological study (Ep.9) and mapping demonstrated a right atria1 automatic focusin three, and focal right atria1 re-entry in two. The atria1 rates of the tachycardias varied between 120-220/min, and were associated with variable AV block. In three patients, the tachycardia was perpetual. These patients had low gated blood pool scan LV ejection fractions that improved post-operatively. The two with paroxysmal tachycardia had normal ejection fractions, and in no patient was there other evidence of structural heart disease. At operation the origins of the tachycardias were determined by epicardial mapping. Complete excision of the origin of tachycardia was achieved in 4 of the 5 patients. EPS two weeks post-operatively showed all patients free from any inducible tachycardia. At follow-up(2-23months), whereas four patients were free from arrhythmias,automatic tachycardia had recurred in one (incomplete excision). Histology of the excised atria1 tissue showed increased fibro-elastic subendocardial tissue in four, and nonspecific changes in one. It is concluded that refractory right atria1 tachycardia can be treated successfully by complete excision of the re-entrant or automatic focus.
Volume 49
WEDNESDAY, APRIL 28, 1982 AM SUPRA VENlRfCULAR TACH YCA RDIA AND PREEXCITA TtDN SYNDROMES 10:30- 12:oo DUAL A-V NODAL PATHWAYS AND ATRIAL FIBRILLATION. Pedro Brugada, MD; Denis Roy; MD; James Weiss, MD; Willem R. Dassen, PhD; Frits W. Bir, MD; Hein 3.5. Wellens, MD, FACC. Department of Cardiology, University of Limburg, Annadal Hospital, Maastricht, The Netherlands. The determinants of the ventricular rate during atria1 fibrillation (AF) in patients (pts) with dual A-V nodal pathways ( DAVNP ) are not known. In 11 consecutive pts with DAVNP having AF lasting longer than I min initiated during programmed electrical stimulation of the heart, the shortest R-R interval (ShRR) and mean ventricular cycle length (MVCL) during AF were measured. These values were compared with the effective refractory period (ERP) and functional (FRP) RP of the fast (f) and the slow (s) AVN P using at least 2 different basic cycle lengths for their measurement. The shortest cycle length with l-to-l A-V conduction was also determined during incremental atria1 pacing. A group of 8 pts with normal A-V nodal function and no evidence for DAVNP served as control. No pts had an accessory pathway. Results: The ShRR during AF ( 350260 ms )was related to the shortest CL with l-to-l A-V conduction ( 358+50 ms ) ( r=+U.95 ), and not to the ERP or FRP of the f 2nd s AVN P. The MVCL during AF ( 486~114 ms ) was not related to any of these variables in pts with DAVNP. The same was found for the control group. There were no differences between the two groups in ShRR and MVCL during AF. CONCLUSIONS: I) The ShRR during AF in pts with or without DAVNP can be predicted from the shortest CL with l-to-l A-V conduction . 2) Retrograde concealed penetration in the f AVNP does not seem to play a role in the MVCL in pts with DAVNP and AF.
ONE-TO-ONE AlRIOVENTRICULAR CONDUCTION DURING ATRIAL
PACING AT RATESOF 300/MIN IN ABSENCE OF WOLFF-PARKINSONWHITEsYNL%UME Federico Moleiro, MD; Agustin Castellanos, MD, FACC; ‘Ivan J. Mendoza. MD: Victor wdina-Ravell. MD; Robert J. Myerburg, MD, FACC,‘Univ. Central de Vene&ela,Caracas, Venezuela and the University of Miami School of Medicine, Miami, Florida. One- to-one atrioventricular
(AV) conduction during atria1 pacing at rates of 300/min has not been reported in absence of Wolff-Parkinson-White syndrome. ‘Ihis exceptional finding was demonstrated in three patients with short PR (and AH)intervals and narrow QRScomplexes. The AH intervals during atria1 pacing at 300/min increased (minimally) to 85, 90 and 90 msec respectively, Case 1 (with normal HV intervals) had fast (290-270/min) ventricular rates during atria1 fibrillation which were decreased to around lOO/min with intravenous verapamil. In Case 2 (also with normal HV intervals) atria1 pacing at rates of 300/min occurred only after atropine administration. In Case 3 the HV intervals were short (25 msec) during sinus rhythm and atria1 pacing at rates of 300/min. However, in echo beats, or when the His bundle was paced, the HV and St-V intervals became normal (40 msec). ‘Ihis patient had episodes of atria1 flutter with 1:l AV conduction which did not respond to verapamil, but to cardioversion. Although the three patients had as “connnondenominators” the short PR intervals and narrow QRScomplexes, they had different electrophysiological mechanisms: spontaneous (Case l), or pharmacological (Case Z), enhanced AV nodal conduction, and atrio (“distal”) His bundle tract (Case 3). The distinct electrophysiological mechanisms may explain the different responses to therapy.
994
March 1982
The American Journal of CARDIOLOGY
EFFECT OF BUNDLE BRANCH BLOCK ON VENTRICULOATRIAL INTERVALS DURING RECIPROCATING TACRYCARDIA IN PATIENTS WITH ACCESSORY ATRIOVENTRICIJLAR PATHWAYS. Charles R. Kerr, MD, John J. Gallagher, MD, FACC, Lawrence D. German, MD. Duke University Medical Center, Durham, N.C. During reciprocating tachycardia in patients with accessory atrioventricular pathways, changes in ventriculoatrial (VA) intervals with bundle branch block (BBB) have been used to localize the site of the pathway and to prove its participation in the tachycardia. We present the changes seen during BBB in 93 patients with single atrioventricular pathways who subsequently had the site of their pathways proven by intraoperative mapping and surgical interruption. In 60 patients with left or right freewall pathways the VA intervals prolonged by 61f9 msec (p
SURGICAL MANAGEMENT OF RIGHT ATRIAL TACHYCAFDIA Paul A. Russell, FRACP, David C. Johnson, FHACS, Alan R. Denniss, MB, David A. Richards, FRACP, John B. Uther, MD, FRACP, Westmead Centre, Sydney, Australia. There have been only two reported cases of excision of an atria1 focus responsible for tachycardia. we present five patients (aged 22-42), with atria1 tachycardia, refractory to medical therapy, who underwent epicardial mapping and excision of the atria1 focus. Pre-operative endocardial electrophysiological study (Ep.9) and mapping demonstrated a right atria1 automatic focusin three, and focal right atria1 re-entry in two. The atria1 rates of the tachycardias varied between 120-220/min, and were associated with variable AV block. In three patients, the tachycardia was perpetual. These patients had low gated blood pool scan LV ejection fractions that improved post-operatively. The two with paroxysmal tachycardia had normal ejection fractions, and in no patient was there other evidence of structural heart disease. At operation the origins of the tachycardias were determined by epicardial mapping. Complete excision of the origin of tachycardia was achieved in 4 of the 5 patients. EPS two weeks post-operatively showed all patients free from any inducible tachycardia. At follow-up(2-23months), whereas four patients were free from arrhythmias,automatic tachycardia had recurred in one (incomplete excision). Histology of the excised atria1 tissue showed increased fibro-elastic subendocardial tissue in four, and nonspecific changes in one. It is concluded that refractory right atria1 tachycardia can be treated successfully by complete excision of the re-entrant or automatic focus.
Volume 49