Clinical, electrocardiographic and electrophysiologic observations in patients with paroxysmal supraventricular tachycardia

Wu, Delon; Denes, Pablo; Amat-y-Leon, Fernando; Dhingra, Ramesh C.; Wyndham, Christopher; Bauernfeind, Robert A.; Latif, Pervaize; Rosen, Kenneth M.

doi:10.1016/0002-9149(78)90856-1

Cited by 372 publications

(60 citation statements)

References 35 publications

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“…Use of increased current may facilitate ventricular capture at coupling intervals short enough to initiate arrhythmias in susceptible patients. Earlier reports of high-currentoutput pacemaker-induced arrhythmias undoubtedly included patients in whom this phenomenon occurred.52 5 Thus, the present studies confirm the importance of programmed stimulation to the study of arrhythmias, but they also suggest that further modifications of this technique may lead to its more optimal use in defining arrhythmia mechanisms, revealing the mechanisms of antiarrhythmic drugs, and in the management of patients with tachyarrhythmias. Such modifications must be evaluated prospectively.…”

Section: Discussionsupporting

confidence: 79%

Strength-interval relations in a chronic canine model of myocardial infarction. Implications for the interpretation of electrophysiologic studies.

Michelson¹,

Spear²,

Moore³

1981

Circulation

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SUMMARY Fifteen adult mongrel dogs underwent two-stage occlusion of the mid-or distal left anterior descending coronary artery and then a reperfusion stage. The dogs were studied 3-30 days later to determine strength-interval relations in a canine model of chronic myocardial infarction. These dogs were susceptible to the initiation of sustained ventricular tachyarrhythmias with the introduction of one, two or three ventricular extrastimuli. Using unipolar cathodal stimuli with a pulse width of 2 msec, strength-interval curves were constructed from measurements made at multiple sites in the distribution of occluded and nonoccluded vessels during drive pacing at a cycle length of 300 msec. At 56 normal sites, ventricular refractory periods measured at twice-diastolic-excitability threshold approximated the relative refractory periods (mean absolute difference 3 msec), but were variably longer than effective refractory periods (mean difference 18 msec, range 4-29 msec). At 51 infarct sites, differences between ventricular refractory periods measured at twice-diastolic-excitability threshold and both relative refractory periods (mean difference 13 msec, range -60 to + 18 msec) and effective refractory periods (mean difference 28 msec, range 1-60 msec) were markedly disparate. These differences were further exaggerated after administration of i.v. procainamide. These findings suggest limitations in interpreting the results of programmed pacing studies performed using stimuli of twice-threshold intensity.PROGRAMMED ELECTRICAL STIMULA-TION has gained acceptance clinically as a means of initiating and terminating sustained tachyarrhythmias,'-8 studying arrhythmia mechanisms,7' 9-12 evaluating properties of excitability and refractoriness,5 13-17 and determining the electrophysiologic effects of various pharmacologic and antiarrhythmic interventions. 4,6,7,13,[18][19][20][21][22] In clinical practice, bipolar pacing via a multipolar catheter is initiated at a rate faster than the patient's intrinsic rate, and the milliamperage of a 1-2-msec pulse is increased until consistent capture is evident.The minimum milliamperage necessary for capture is then defined as the excitability threshold for that site.23 Routinely, clinical electrophysiologic studies have been performed at a milliamperage approximately twice the excitability threshold, and usually at less than 3 mA. 4' 7, 8, 24 Such methods have been considered adequate for obtaining necessary electrophysiologic information and safe enough to avoid inadvertent ventricular fibrillation.7 8,25 However, no specific data suggest that performing programmed electrical stimulation at twice-diastolic-threshold intensity is optimal. Even in the most experienced clin- Materials and Methods Studies were performed on 15 healthy adult mongrel dogs that weighed 8-16 kg. The dogs were anesthetized with i.v. sodium pentobarbital (30 mg/kg) and then ventilated with room air through a cuffed pharyngeotracheal tube using a volume-cycled positive-pressure respirator. Body temperature was ma...

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Section: Discussionsupporting

confidence: 79%

Strength-interval relations in a chronic canine model of myocardial infarction. Implications for the interpretation of electrophysiologic studies.

Michelson¹,

Spear²,

Moore³

1981

Circulation

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“…Diagnosis of common AVNRT was made based on the following findings: 1) Antegrade dual AVN pathways defined as discontinuous AV conduction curve with an increase in the A2-H2 interval of >50 msec in response to a decrease in the A1-A2 interval of 10 msec were demonstrated; 2) initiation of the tachycardia was dependent on the achievement of a critical delay in the AH interval; 3) retrograde earliest atrial activation during tachycardia was registered in the His bundle electrogram; and 4) premature ventricular extrastimuli introduced during tachycardia when the His-bundle was refractory to retrograde conduction did not advance the subsequent atrial activation. 16,24) Diagnosis of the uncommon AVNRT was made based on the following findings; 1) Presence of retrograde slow pathway conduction with decremental conduction properties was demonstrated; 2) initiation of the tachycardia was related to a shift of the retrograde conduction from the fast pathway to the slow pathway or critical prolongation of the retrograde slow pathway conduction; 3) retrograde earliest atrial electrogram during tachycardia was registered at the posterior right atrial septum; 4) premature ventricular extrastimulus introduced during tachycardia when the His-bundle was refractory to retrograde conduction did not advance the subsequent atrial activation; and 5) the exclusion criteria of atrial tachycardia previously described were satisfied. 16,23,24) Ablation procedure:…”

Section: Study Populationmentioning

confidence: 99%

“…16,24) Diagnosis of the uncommon AVNRT was made based on the following findings; 1) Presence of retrograde slow pathway conduction with decremental conduction properties was demonstrated; 2) initiation of the tachycardia was related to a shift of the retrograde conduction from the fast pathway to the slow pathway or critical prolongation of the retrograde slow pathway conduction; 3) retrograde earliest atrial electrogram during tachycardia was registered at the posterior right atrial septum; 4) premature ventricular extrastimulus introduced during tachycardia when the His-bundle was refractory to retrograde conduction did not advance the subsequent atrial activation; and 5) the exclusion criteria of atrial tachycardia previously described were satisfied. 16,23,24) Ablation procedure:…”

Section: Study Populationmentioning

confidence: 99%

Selective Radiofrequency Catheter Ablation of the Slow Pathway for Common and Uncommon Atrioventricular Nodal Reentrant Tachycardia.

et al. 1996

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SUMMARYThe utility of selective radiofrequency catheter ablation of the slow pathway for the treatment of common and uncommon atrioventricular nodal reentrant tachycardia (AVNRT) was studied in 110 consecutive patients, 94 with slow-fast form common AVNRT, and 11 and 5, respectively, with the fast-slow and slow-slow forms of uncommon AVNRT. Ablation sites were determined by mapping a late and spiky "slow pathway potential" in the posterior right atrial septum in common AVNRT, and also the earliest retrograde atrial activation over the retrograde slow pathway in uncommon AVNRT. AVNRT was successfully eliminated in all patients with a mean number of radiofrequenc pulses of 2.93.0 and a mean total energy applied of 35362996 joules. There were no early or late complications, except for transient AV block for 15 sec immediately after energy application in one common AVNRT patient, and no recurrence of AVNRT in a mean follow-up period of 2413 months. There were no significant differences between common and uncommon AVNRT in success rate, mean application number and total energy applied. However, the AVN physiology post-ablation was different. Slow pathway conduction was eliminated in only 32% of the patients post-ablation in common AVNRT, while it was eliminated in 100% in uncommon AVNRT.Selective radiofrequency catheter ablation of the slow pathway can cure common and uncommon AVNRT effectively and safely. Common AVNRT can be eliminated irrespective of the persistence of slow pathway conduction, while uncommon AVNRT can be eliminated by the eradication of slow pathway conduction.

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“…The atrial fusion was critically related to conduction time from the atrial pacing site to the atrial recording sites and to slow conduction within the reentry loop, i.e., to slow conduction in the AV node (figs. [3][4][5].…”

mentioning

confidence: 99%

Transient entrainment and interruption of the atrioventricular bypass pathway type of paroxysmal atrial tachycardia. A model for understanding and identifying reentrant arrhythmias.

et al. 1983

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SUMMARY We studied transient entrainment and interruption of atrioventricular (AV) bypass pathway-type paroxysmal atrial tachycardia in 15 patients during overdrive pacing from selected atrial sites. Overdrive atrial pacing at less than a critically rapid rate for interruption transiently entrained the tachycardia. Transient entrainment was due to repeated early entrance of the wave front from the pacing impulse into the reentry loop in both antidromic and orthodromic directions. The antidromic wave front of each pacing impulse was repeatedly blocked as it collided with the orthodromic wave front of the previous beat, in effect extinguishing the tachycardia. However, the early entrance of the orthodromic wave front of each pacing impulse repeatedly reset the tachycardia. The result was that during transient entrainment, the tachycardia rate increased to the pacing rate. Interruption of the tachycardia occurred when overdrive pacing produced block within the reentry loop of both the antidromic and orthodromic wave fronts of the same pacing impulse, the block occurring either at separate sites within the reentry loop or at the same site. Atrial fusion beats were demonstrated during transient entrainment in nine patients and resulted from intraatrial collision of the antidromic wave front from the pacing impulse with the orthodromic wave front of the previous beat. The presence offusion beats depended critically on the relationship of the pacing site to the reentry loop and the duration of conduction around the reentry loop, particularly through the area of slow conduction.The data from this study suggest that (1) if one can demonstrate constant fusion beats during transient entrainment of a tachyarrhythmia except for the last transiently entrained beat; or (2) if during transient entrainment of a tachyarrhythmia at two or more different pacing rates, one can demonstrate constant fusion at each of the different pacing rates, but different degrees of fusion at the different rates; or (3) if interruption of a tachyarrhythmia by overdrive pacing is associated with localized conduction block to a site followed by activation of that site by the next pacing impulse from a different direction and with a shorter conduction time, then the underlying mechanism of the arrhythmia can be best explained by reentry.PAROXYSMAL atrial tachycardia that involves antegrade conduction from the atria through the atrioventricular (AV) node-His-Purkinje system to the ventricles with retrograde conduction from the ventricles via an AV bypass pathway back to the atria is the best understood example of putative reentrant rhythms.1AThis arrhythmia is often found in patients with the Wolff-Parkinson-White syndrome and in patients with a so-called concealed AV bypass pathway, i.e., one that conducts only in the retrograde direction. The many types of treatment for this arrhythmia include its interruption by overdrive cardiac pacing.' We have found that overdrive pacing used to interrupt paroxysmal atrial tachycardia of this variety has much in ...

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Clinical, electrocardiographic and electrophysiologic observations in patients with paroxysmal supraventricular tachycardia

Cited by 372 publications

References 35 publications

Strength-interval relations in a chronic canine model of myocardial infarction. Implications for the interpretation of electrophysiologic studies.

Strength-interval relations in a chronic canine model of myocardial infarction. Implications for the interpretation of electrophysiologic studies.

Selective Radiofrequency Catheter Ablation of the Slow Pathway for Common and Uncommon Atrioventricular Nodal Reentrant Tachycardia.

Transient entrainment and interruption of the atrioventricular bypass pathway type of paroxysmal atrial tachycardia. A model for understanding and identifying reentrant arrhythmias.

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