Variants of preexcitation: the tough stuff Case #4. Sergio Richter, MD Heart Center University of Leipzig

Transcription

1 Variants of preexcitation: the tough stuff Case #4 Sergio Richter, MD eart Center University of Leipzig

2 Variants of preexcitation the tough stuff Presenter disclosure information Sergio Richter has received lecture fees from St. Jude Medical and Biotronik.

3 Medical history 41-year-old female with a long-standing history of recurrent fast and regular palpitations with sudden on- and offset; negative frog-sign No evidence of structural heart disease on non-invasive examination Several documentations of a verapamil-sensitive wide QRS-complex tachycardia with RBBB-like morphology and left superior axis deviation Previous EPS and slow-pathway ablation one year ago

4 Physical examination Physical examination was unremarkable, normal blood pressure (120/80 mmg), no cardiac murmurs or abnormal heart sounds on auscultation

5 12-lead ECG at admission

6 Clinical wide QRS-complex tachycardia recorded in the ER

7 Tachycardia CL prolongation during verapamil 5 mg IV

8 Tachycardia termination during verapamil 5 mg IV

9 Baseline 12-lead ECG

10 Baseline 12-lead ECG = 650 ms = 60 ms V = 40 ms

11 Incremental ventricular pacing PCL = 500 ms RB RB V septal = 130 ms

12 Incremental ventricular pacing PCL = 400 ms RB RB V septal = 150 ms

13 Incremental ventricular pacing PCL = 300 ms

14 Induction of clinical tachycardia by PVS (500 S2)

15 Induction of clinical tachycardia by PVS (500 S2)

16 Incremental atrial pacing PCL = 600 ms PCL = 500 ms PCL = 400 ms PCL = 300 ms

17 trial extrastimuli pacing S1 S1 S2 S3 *

18 denosine 18 mg IV

19 Differential diagnosis Ventricular tachycardia with 1:1 V conduction Preexcited tachycardia (antidromic V reentrant tachycardia) VNRT with innocent bystander V conduction over an accessory pathway

20 Is there an accessory pathway present? If yes... Normal V pathway? Decremental conduction? Nodofascicular or -ventricular pathway? Latent Mahaim? Bystander V conduction over an P?

21 Is there an accessory pathway present? If yes... Normal V pathway? No. Decremental conduction?

22 Decremental conduction? Sternick et al., eart Rhythm 2009;6:

23 Decremental conduction? S1 S1 S2 S3 S3 290 ms V 280 ms V 80 ms

24 Decremental conduction? S1 S1 S2 S3 S3 270 ms V 320 ms V 80 ms

25 Decremental conduction? eart Rhythm 2009;6:

26 Decremental conduction? V = 180 ms TCL = 300 ms V/TCL = 0.6 eart Rhythm 2009;6: ms V

27 Is there an accessory pathway present? If yes... Normal V pathway? No. Decremental conduction? Yes. Nodofascicular or -ventricular pathway?

28 Nodofascicular pathway? * V

29 Nodoventricular pathway? Pro nterograde P conduction seems to be linked to V nodal conduction Decremental anterograde P conduction properties denosine-sensitive P bsence of retrograde P conduction Constant V interval of preexcited beats (upon atrial extrastimuli pacing and during tachycardia) Contra QRS morphology Previous slow-pathway ablation

30 Is there an accessory pathway present? If yes... Normal V pathway? No. Decremental conduction? Yes. Nodofascicular or -ventricular pathway? NV-P possible. Latent Mahaim?

31 Latent Mahaim? Sternick et al., eart Rhythm 2009;6:

32 Is there an accessory pathway present? If yes... Normal V pathway? No. Decremental conduction? Yes. Nodofascicular or -ventricular pathway? NV-P possible. Latent Mahaim? Possibly (strange one). Bystander V conduction over an P?

33 Late PC on septal atrial refractoriness

34 Late PC on septal atrial refractoriness V V V V V V

35 Late PC on septal atrial refractoriness S

36 Late PC on septal atrial refractoriness S V V V V V V V

37 Is there an accessory pathway present? If yes... Normal V pathway? No. Decremental conduction? Yes. Nodofascicular or -ventricular pathway? No. NV-P possible. Latent Mahaim? Possibly (strange one). Bystander V conduction over an P? No.

38 Differential diagnosis Ventricular tachycardia with 1:1 V conduction Preexcited tachycardia (antidromic V reentrant tachycardia) VNRT with innocent bystander V conduction over an accessory pathway

39 Mapping and ablation *

40 Mapping and ablation P-like potential at right mid-septal T

41 Mapping and ablation P-like potential - within proximal CS CL 400 ms

42 Mapping and ablation P-like potential left septal

43 Mapping and ablation

44 Mapping and ablation

45 Clinical course Symptom- and arrhythmia-free at 2-years follow-up.

46 Concluding remarks Most likely diagnosis: Latent decrementally conducting atrioventricular accessory pathway Mimicking the presence of a nodoventricular connection (actively involved in tachycardia or as bystander) Long course of P from atrial RMS region to left septal ventricular insertion side JCE 2005;16:

47 Concluding remarks No looking while cooking be smart and try your very best to arrhythmia-understanding and diagnosis-making before buring!!!

48

49 cknowledgement PCE 2010;33:e76-e80

50 Previous EP study Report: Reproducible induction of the clinical wide QRS-complex tachycardia with jump and 1 VNE during atrial extrastimuli pacing with S2 (600/230 ms). No clear B recording during tachy, no reset of tachycardia with late PC. ypothesis: VNRT with bystander V conduction over a nodoventricular pathway; decision to ablate the slow pathway. fter ablation at SP region, no occurrence of typical jump and VNE anymore, but still induction of the clinical wide QRS-complex tachycardia, now only by PVS (S2).

51 Previous EP study

52 Mapping and ablation

53