Manifest para-Hisian accessory Pathway (WPW)

ablation Dr. Ahmed Taha Hussein

M.Sc.cardiologyAssistant lecturer of cardiology, EPS

Zagazig university, EGYPT

ECRA 2013 - EGYPTECRA 2013 - EGYPT

Our EPSEPS team

History

Male pt. 16 years old with irrelevant medical or family history .

Gives history of recurrent attacks of palpitation mostly of rapid regular pattern , but sometimes irregular since he was 9 years old .

His parents also reported recurrent attacks of syncope for few minutes.

3 month ago , he developed syncope in the street, the witness reported that the ambulance paramedics gave him DC shock .

Past medical History

The patient underwent EP-Study 2009 , because of documented SVT , was thought to be ( AVNRT ) according to his event ECG.

Post operative report : ablation of slow Pathway with lost AH jump , but with trial of induction of tachycardia , he developed wide QRS tachycardia , deduced to be AVRT using incessant AP , but they failed to ablate , giving hint that the AP may be postro-septal .

Physical examination

Was unremarkable except for :He Looks very tall relative to his age ( >2

SD ), with high arched palate , and malleable joints.

His cardiac examination , revealed MR of grade I/IV .

Marfan like picture .

Echocardiography

Normal LV function and internal dimensions.

Dilated aortic root AoR=43 mm . 1st degree Mitral valve prolapse with trivial

eccentric MR. Normal PAP , and right side of the heart.LAB investigations were totally normal .

ECG before procedure WPW : overt AP, short PR , wide QRS , delta wave. Location : parahissian Vs antroseptal AP : +ve delta in I,II ,III , avF V3-V6 ------ve avL , avR , V1

ECG

ECG before procedure WPW : overt AP, short PR , wide QRS , delta wave. Location : parahissian Vs antroseptal AP : +ve delta in I,II ,III , avF V3-V6 ------ve avL , avR , V1,V2

ECG –orthodromic AVRT

HOLTER study

Recurrent Attacks of Narrow QRS tachycardia mostly orthodromic AVRT

Intermittent WPW ( delta + short PR +wide QRS ).

Atrial fibrillation . Wide QRS tachycardia mostly Antridromic

AVRT.

Narrow QRS variable RR , absent P-wave tachycardia AF

Intermittent pre-excitation

Pre-excited AF

EP-LAB

consent was taken and informed about the complication of the procedure .

Briefly, 2 quadri-polar catheters were introduced through right femoral veins and left subclavian deca-polar and placed respectively in His bundle region, right ventricle, coronary sinus (CS), and ablation 4mm for mapping and ablation.

A H’V

Fluoroscopic views

LAORAO

ABL

Atrial pacing

AV

Narrowest AV in HISS record with no H potential

Antidromic AVRT with very short VA time with early V at Hiss record

V A

AV=40ms

A V

RF=20J for 10 sec

Junctional Rhythm

RF

During successful ablation : Delta disappeared and AV time normalize

RF

RF=20J for 30 sec

During successful ablation of APDelta disappeared and PR interval normalize

Post ablation

AH=100ms

Atrial pacing

ECG post procedure

Post ablation testing

Programmed Burst ,decremental, extra-stimulation of Atrial and ventricular pacing to test the conductivity of the AP , revealed no conduction( block) in either directions (antegrade & retrograde), and no tachycardia was induced .

Concentric conduction ,through AVN reaching wenchbach point with 500/260 ms.

Normal intact AVN conduction. Differential ventricular pacing to test AP

conductivity revealed block.

Follow UP

3 month later holter study done :No arrhythmia detected either of narrow or

wide QRS .Normal Sinus rhythm , normal PR

interval , narrow QRS complex.

Take home message Surface ECG has low specificity in accurate localization

of septal Accessory pathways , and EPS is mandatory for accurate localization of septal APs.

Septal APs have special behavior of “pathway slant “pathway slant ” ” which needed to be taken in consideration when ablating to avoid collateral damage.

EPS not only to confirm AVRT, but needed to exclude other type of arrhythmia may be coincidental.

AF associated with WPW found to vanish with successful AP ablation in 90% of cases.

Although AP may be localized in potentially dangerous areas, no serious complication occur if AP potential is accurately identified and recorded representing the optimal ablation target .

Thank youThank you

نوصل يوم في لبد

نحلم بس .!!