Markers of coronary sinus accessory pathways in pediatrics.
ABSTRACT Coronary sinus accessory pathways (CSAPs), atrioventricular connections formed by the coronary sinus myocardial coat, have been described in adult patients, but not systematically described in pediatric patients.
Patients who underwent CSAP ablation were compared to patients with right posteroseptal (RPS) pathway ablation (control group) from November 2004 to June 2007. Retrospective reviews of preablation 12-lead electrocardiogram (EKG), fluoroscopic, and intracardiac electrogram data were then performed to identify electrophysiologic markers of CSAP.
A total of 23 patients were identified: 13 with CSAP and 10 with RPS pathways. Preablation EKGs demonstrated preexcitation in 8/10 (80%) patients with RPS pathways versus 9/13 (69%) patients with CSAP (P = 0.66). Preexcitation with a negative delta wave in lead II was seen in 5/9 (56%) patients with CSAP versus 0/8 in RPS (P = 0.029), and preexcitation with a positive delta wave in augmented vector right (aVR) was seen in 9/9 (100%) patients with CSAP versus 3/8 (37.5%) with RPS (P = 0.009). Accessory pathway (AP) potentials were seen on the coronary sinus (CS) catheter in 6/13 (46%) of CSAP and in 0 RPS ablations (P = 0.019). Recurrence of tachycardia occurred in 5/13 (38%) of patients with CSAP and 1/10 (10%) of patients with RPS pathways (P = 0.18).
CSAPs should be considered when preablation EKG demonstrates preexcitation with a negative delta wave in lead II and a positive delta wave in aVR, and if an AP potential is seen on the CS catheter. Recurrence of tachycardia postablation or the need for multiple ablations should raise suspicion for a CSAP.
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ABSTRACT: Radiofrequency catheter ablation of left-sided accessory pathways (APs) with the use of an endocardial technique carries all potential risks of left heart catheterization. We analyzed the determinants of success, efficacy, and safety of radiofrequency catheter ablation from the coronary sinus (CS), as a potential alternative to the endocardial technique in these patients. Thirteen patients (mean age 40 +/- 20 years) with 15 left-sided APs and a history of symptomatic supraventricular tachycardia were included in the study. Nine APs were localized in the left posteroseptal region, and the remaining 6 in the left free wall. Ablation from CS was attempted in 12 patients with 14 APs. In 1 patient ablation within the CS was not deemed safe because of a small venous lumen. All 14 APs were successfully ablated using either CS ablation alone or combined with the endocardial technique. Efficacy of the CS ablation as a primary technique was 56% (5 of 9 APs). In 5 additional APs, ablation in the CS eliminated pathway conduction after failed endocardial attempts. CS ablation either as a primary or a secondary technique eliminated conduction in 10 of 14 APs (71.4%) (group 1). In the remaining 4 APs (group 2), the primary CS attempt was unsuccessful and APs were ablated with a subsequent endocardial approach. Determinants of success for the CS method were local AP to atrial and/or ventricular electrogram amplitude ratios > or = 1 (p < 0.05). The success rate of CS ablation was 83% in the left posteroseptal APs adjoining the branching point of the middle cardiac vein or a CS anomaly.(ABSTRACT TRUNCATED AT 250 WORDS)The American Journal of Cardiology 08/1995; 76(5):359-65. · 3.21 Impact Factor
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ABSTRACT: The purpose of this study was to determine the incidence and types of venous branches and anomalies in posteroseptal accessory pathways (APs) and whether these findings are indicative for successful ablation sites. Some posteroseptal APs may be located epicardially, or may be associated with venous anomalies or related to the middle cardiac vein. These APs account for many of the failures encountered during endocardial ablation. Direct coronary sinus (CS) angiography was performed in 43 consecutive patients with left posteroseptal APs (n = 23) and in 20 patients with AV nodal reentrant tachycardia prior to catheter ablation. In 14 (61%) of 23 APs, a venous branch or an anomaly of the CS was found in the posteroseptal region (6 with middle cardiac vein, 2 with other ventricular venous branches, and 6 had a diverticulum). Eleven (48%) of 23 APs were successfully abolished from within that demonstrated venous system, with a median of four radiofrequency impulses. In the remaining 12 (52%) patients, ablation was attempted from the endocardial site of the mitral annulus. Repeat angiography after energy delivery revealed no major complications in any patient. One (5%) patient with AV nodal reentrant tachycardia had evidence of a CS anomaly (P < 0.01). Various types of venous branches and anomalies are associated with the majority of patients with left posteroseptal APs. The APs are directly related to these complex findings, and AP conduction can easily be eliminated from within the venous branches. CS angiography is suggested prior to catheter ablation of left posteroseptal APs to facilitate the ablation procedure.Pacing and Clinical Electrophysiology 08/1996; 19(7):1075-81. · 1.75 Impact Factor
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ABSTRACT: Accessory pathways (APs) that can only be ablated from the coronary sinus are likely to be located subepicardially. The electrocardiographic (ECG) and electrophysiological characteristics as well as the immediate radiofrequency ablation success rate and the recurrence rate were compared in 15 patients (11 posteroseptal and 4 left free-wall) with subepicardial APs and in 31 control patients with posteroseptal (15) and left free-wall (16) APs matched with age, sex, and AP location during the same study period in whom APs were successfully ablated from the endocardial approach. Patients with posteroseptal subepicardial APs had a longer tachycardia cycle length (355 +/- 32 vs 286 +/- 49 milliseconds, P < .05), a lower success rate (9 /11 vs 15/15, P = .09), and a higher recurrence rate (3/9 vs 0/15, P < .05) as compared with control patients. A negative delta wave with QS or QR pattern in lead II was present in all 4 patients with a manifest posteroseptal subepicardial AP located in the middle cardiac vein as compared with none of the 5 control patients with posteroseptal APs located in the proximal coronary sinus and 1 of the 9 control patients (P < .01). A positive delta wave in lead I along with an R/S of less than 1 in lead V 1 , and a negative delta wave in lead II, was noted in 1 of the 2 patients with left free-wall subepicardial APs and none of the 7 controls (P = .047). The local activation time is significantly shorter in the 4 patients with left free-wall subepicardial AP than in the 16 control patients (31 +/- 9 vs 89 +/- milliseconds, P = .044). CONCLUSIONS: Some ECG characteristics are suggestive of APs located in the middle cardiac vein and left free-wall subepicardial site, while a longer local activation time is characteristic of left free-wall APs. The success rate is lower and the recurrence rate higher with radiofrequency ablation in patients with subepicardial AP.Journal of Electrocardiology 02/2005; 38(1):69-76. · 1.09 Impact Factor