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Enriquez A, Gonzalez R, Kumareswaran R, Supple G, Scheinman M. Electrophysiologic diagnosis of narrow and wide complex tachyarrhythmias. Heart Rhythm 2024; 21:2215-2225. [PMID: 38734227 DOI: 10.1016/j.hrthm.2024.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Revised: 05/01/2024] [Accepted: 05/03/2024] [Indexed: 05/13/2024]
Abstract
Establishing the precise mechanism of cardiac arrhythmias in the electrophysiology laboratory is one of the main requisites for a successful and safe ablation. This article provides an organized approach to the differential diagnosis of narrow and wide complex tachycardias based on the analysis of electrical activation patterns, followed by specific pacing maneuvers in each case.
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Affiliation(s)
- Andres Enriquez
- Section of Cardiac Electrophysiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
| | | | - Ramanan Kumareswaran
- Section of Cardiac Electrophysiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gregory Supple
- Section of Cardiac Electrophysiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Melvin Scheinman
- Division of Electrophysiology, Department of Cardiology, University of California San Francisco, San Francisco, California
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2
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Park S, Park JW, Kim S, Kim H, Kim SH, Oh YS, Choi Y. Upper common pathway analysis using late atrial premature depolarization in atrioventricular nodal reentry tachycardia. Heart Rhythm 2024; 21:1729-1734. [PMID: 38552730 DOI: 10.1016/j.hrthm.2024.03.1788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 03/21/2024] [Accepted: 03/25/2024] [Indexed: 04/18/2024]
Abstract
BACKGROUND Anatomic and electrophysiologic findings suggest that the actual circuit of atrioventricular nodal reentrant tachycardia (AVNRT) involves the perinodal atrium. However, occasional instances in which the atrium is dissociated from the AVNRT have led to the concept of an upper common pathway (UCP). OBJECTIVE We aimed to assess the prevalence of UCP in AVNRT using a late atrial premature depolarization (LAPD) maneuver. METHODS Patients who were diagnosed with typical AVNRT by electrophysiologic studies were enrolled. For evaluation of the presence of UCP, an LAPD was given at the coronary sinus ostium (osCS) during AVNRT, and then pacing was repeated incrementally every 10 ms. Electrograms in the earliest retrograde atrial activation site (ERAS) near the proximal His were mapped and recorded during the pacing. Results were interpreted as follows: absence of UCP-an LAPD from the osCS can reset the tachycardia without depolarizing the ERAS; presence of UCP-an LAPD from the osCS can depolarize the ERAS without resetting the tachycardia; and indeterminate-an LAPD from the osCS either resets the ERAS and tachycardia simultaneously or does not reset both. RESULTS The LAPD maneuver was performed in 126 patients with AVNRT. It demonstrated an absence of UCP in 121 (96.0%) patients and the presence of UCP in 3 (2.4%) patients; the result was indeterminate in 2 (1.6%) patients. CONCLUSION The LAPD maneuver revealed that the presence of UCP is indicated in only rare cases of AVNRT. In most AVNRT cases, the atrium is involved in the reentry circuit.
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Affiliation(s)
- Soyoon Park
- Division of Cardiology, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Cardiovascular Research Institute for Intractable Disease, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jeong-Wook Park
- Division of Cardiology, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Soohyun Kim
- Division of Cardiology, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Cardiovascular Research Institute for Intractable Disease, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hwajung Kim
- Cardiovascular Research Institute for Intractable Disease, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Division of Cardiology, Department of Internal Medicine, Yeouido St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sung-Hwan Kim
- Division of Cardiology, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Cardiovascular Research Institute for Intractable Disease, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yong-Seog Oh
- Division of Cardiology, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Cardiovascular Research Institute for Intractable Disease, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Young Choi
- Division of Cardiology, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Cardiovascular Research Institute for Intractable Disease, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
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Aslan AO, Merovci I, Tunçez A, Oksuz F, Kara M, Cetin EHO, Korkmaz A, Ozeke O, Cay S, Ozcan F, Aras D, Topaloglu S. Simultaneous narrow and wide QRS complex tachycardia: Misdiagnosis or Missed diagnosis? J Cardiovasc Electrophysiol 2022; 33:1599-1604. [PMID: 35612357 DOI: 10.1111/jce.15560] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 05/17/2022] [Accepted: 05/22/2022] [Indexed: 11/30/2022]
Abstract
Tachycardia-induced tachycardia, or so-called double tachycardia, appears to be a relatively rare condition. Regardless of the mechanism, this case illustrates the importance of assessing the response to multiple different pacing maneuvers in determining the mechanism of narrow and wide QRS complex tachycardias, rather than relying upon a single maneuver, even one that is believed to be diagnostic. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Ahmet Oguz Aslan
- Health Sciences University, Ahi Evren Thoracic and Cardiovascular Surgery Training and Research Hospital, Trabzon, Turkey
| | - Idriz Merovci
- University Clinical Center of Kosovo, Department of Cardiology, Prishtina, Kosovo, Turkey
| | | | - Fatih Oksuz
- Health Sciences University, Ankara Education and Research Hospital, Department of Cardiology, Ankara, Turkey
| | - Meryem Kara
- Health Sciences University, Ankara City Hospital, Department of Cardiology, Ankara, Turkey
| | - Elif Hande Ozcan Cetin
- Health Sciences University, Ankara City Hospital, Department of Cardiology, Ankara, Turkey
| | - Ahmet Korkmaz
- Health Sciences University, Ankara City Hospital, Department of Cardiology, Ankara, Turkey
| | - Ozcan Ozeke
- Health Sciences University, Ankara City Hospital, Department of Cardiology, Ankara, Turkey
| | - Serkan Cay
- Health Sciences University, Ankara City Hospital, Department of Cardiology, Ankara, Turkey
| | - Firat Ozcan
- Health Sciences University, Ankara City Hospital, Department of Cardiology, Ankara, Turkey
| | - Dursun Aras
- İstanbul Medipol University, Department of Cardiology, İstanbul, Turkey
| | - Serkan Topaloglu
- Health Sciences University, Ankara City Hospital, Department of Cardiology, Ankara, Turkey
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4
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Turan T, Hidayet Ş, Tunçez A, Sertdemir AL, Deveci B, Celik IE, Kara M, Korkmaz A, Ozeke O, Cay S, Ozcan F, Aras D, Topaloglu S. An interesting response to His-synchronous ventricular stimulation: What is the mechanism of this supraventricular tachycardia?". J Cardiovasc Electrophysiol 2022; 33:1051-1054. [PMID: 35304936 DOI: 10.1111/jce.15450] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 03/02/2022] [Accepted: 03/07/2022] [Indexed: 11/28/2022]
Abstract
Inappropriate therapies are frequent in patients with ICDs and are associated with adverse outcomes, including increased mortality. Atrioventricular nodal reentrant tachycardia (AVNRT) is the most common reentrant narrow complex tachycardia and a cause of inappropriate therapies in these patients. The differential diagnosis of narrow QRS complex tachycardia with ventriculoatrial (VA) dissociation or variable block to the atrium is a pivotal role to avoid inappropriate ICD implantation or then shock therapies. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Turhan Turan
- Health Sciences University, Ahi Evren Thoracic and Cardiovascular Surgery Training and Research Hospital, Trabzon, Turkey
| | - Şiho Hidayet
- Inonu University, Department of Cardiology, Malatya, Turkey
| | | | - Ahmet Lutfu Sertdemir
- Necmettin Erbakan University Meram Medical Faculty, Department of Cardiology, Konya, Turkey
| | - Bulent Deveci
- Health Sciences University, Ankara City Hospital, Department of Cardiology, Ankara, Turkey
| | - Ibrahim Etem Celik
- Health Sciences University, Ankara Education and Research Hospital, Department of Cardiology; Ankara, Turkey
| | - Meryem Kara
- Health Sciences University, Ankara City Hospital, Department of Cardiology, Ankara, Turkey
| | - Ahmet Korkmaz
- Health Sciences University, Ankara City Hospital, Department of Cardiology, Ankara, Turkey
| | - Ozcan Ozeke
- Health Sciences University, Ankara City Hospital, Department of Cardiology, Ankara, Turkey
| | - Serkan Cay
- Health Sciences University, Ankara City Hospital, Department of Cardiology, Ankara, Turkey
| | - Firat Ozcan
- Health Sciences University, Ankara City Hospital, Department of Cardiology, Ankara, Turkey
| | - Dursun Aras
- İstanbul Medipol University, Department of Cardiology, İstanbul, Turkey
| | - Serkan Topaloglu
- Health Sciences University, Ankara City Hospital, Department of Cardiology, Ankara, Turkey
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Sriramoju A, Srivathsan K, Shen WK. Incessant supraventricular tachycardia following tricuspid valve repair: Unmasking of a nodoventricular pathway. HeartRhythm Case Rep 2021; 8:167-170. [PMID: 35492851 PMCID: PMC9039546 DOI: 10.1016/j.hrcr.2021.11.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Viswanathan MN, Julie He B, Sung R, Hoffmayer KS, Badhwar N, Lee A, Goldberger JJ, Hsia HH, Jackman WM, Scheinman MM. Importance of the Activation Sequence of the His or Right Bundle for Diagnosis of Complex Tachycardia Circuits. Circ Arrhythm Electrophysiol 2021; 14:e009194. [PMID: 34601885 DOI: 10.1161/circep.120.009194] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In this review, we emphasize the unique value of recording the activation sequence of the His bundle or right bundle branch (RB) for diagnoses of various supraventricular and fascicular tachycardias. A close analysis of the His to RB (H-RB) activation sequence can help differentiate various forms of supraventricular tachycardias, namely atrioventricular nodal reentry tachycardia from concealed nodofascicular tachycardia, a common clinical dilemma. Furthermore, bundle branch reentry tachycardia and fascicular tachycardias often are included in the differential diagnosis of supraventricular tachycardia with aberrancy, and the use of this technique can help the operator make the distinction between supraventricular tachycardias and these other forms of ventricular tachycardias using the His-Purkinje system. We show that this technique is enhanced by the use of multipolar catheters placed to span the proximal His to RB position to record the activation sequence between proximal His potential to the distal RB potential. This allows the operator to fully analyze the activation sequence in sinus rhythm as compared to that during tachycardia and may help target ablation of these arrhythmias. We argue that 3 patterns of H-RB activation are commonly identified-the anterograde H-RB pattern, the retrograde H-RB (right bundle to His bundle) pattern, and the chevron H-RB pattern (simultaneous proximal His and proximal RB activation)-and specific arrhythmias tend to be associated with specific H-RB activation sequences. We show that being able to record and categorize this H-RB relationship can be instrumental to the operator, along with standard pacing maneuvers, to make an arrhythmia diagnosis in complex tachycardia circuits. We highlight the importance of H-RB activation patterns in these complex tachycardias by means of case illustrations from our groups as well as from prior reports.
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Affiliation(s)
| | - Beixin Julie He
- University of California, San Francisco, CA (B.J.H., A.L., H.H.H., M.M.S.)
| | | | | | - Nitish Badhwar
- Stanford University School of Medicine, CA (M.N.V., N.B.)
| | - Adam Lee
- University of California, San Francisco, CA (B.J.H., A.L., H.H.H., M.M.S.)
| | | | - Henry H Hsia
- University of California, San Francisco, CA (B.J.H., A.L., H.H.H., M.M.S.)
| | - Warren M Jackman
- University of Oklahoma School of Medicine, Oklahoma City (W.M.J.)
| | - Melvin M Scheinman
- University of California, San Francisco, CA (B.J.H., A.L., H.H.H., M.M.S.)
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Abualsuod AM, Miller JM. Removing the complexity from wide complex tachycardia. Trends Cardiovasc Med 2021; 32:221-225. [PMID: 33838244 DOI: 10.1016/j.tcm.2021.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 04/03/2021] [Accepted: 04/04/2021] [Indexed: 12/13/2022]
Abstract
Correctly diagnosing the cause of wide QRS tachycardias remain an area of difficulty for many clinicians. The authors provide a concise update to the different ECG algorithms that have been developed as well as caveats in their application.
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Affiliation(s)
- Amjad M Abualsuod
- Department of Medicine, Krannert Institute of Cardiology, Indiana University School of Medicine, E-488 1800 N. Capitol Ave., Indianapolis, IN 46202, United States
| | - John M Miller
- Department of Medicine, Krannert Institute of Cardiology, Indiana University School of Medicine, E-488 1800 N. Capitol Ave., Indianapolis, IN 46202, United States.
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Korkmaz A, Kara M, Ozeke O, Cay S, Ozcan F, Topaloglu S, Aras D. Termination, Advancement, and Delaying Responses to His Synchronous Premature Ventricular Contractions During Narrow QRS Tachycardia: What Are the Possible Mechanisms? J Innov Card Rhythm Manag 2021; 12:4376-4380. [PMID: 33520354 PMCID: PMC7834043 DOI: 10.19102/icrm.2021.120108] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Accepted: 09/22/2020] [Indexed: 12/13/2022] Open
Abstract
The differential diagnosis of a regular, narrow QRS, long-R-P tachycardia includes atypical atrioventricular nodal reentry tachycardia, atrial tachycardia, and atrioventricular reentry tachycardia via a slowly conducting accessory pathway with decremental conduction properties. Almost all described diagnostic maneuvers in the electrophysiology laboratory have exceptions to their primary interpretation. The usual proviso is that the observation must be reproducible.
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Affiliation(s)
- Ahmet Korkmaz
- Department of Cardiology, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Meryem Kara
- Department of Cardiology, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Ozcan Ozeke
- Department of Cardiology, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Serkan Cay
- Department of Cardiology, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Firat Ozcan
- Department of Cardiology, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Serkan Topaloglu
- Department of Cardiology, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Dursun Aras
- Department of Cardiology, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
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9
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Wang W, Jiang TF, Han WZ, Jin L, Zhao XJ, Guo Y. Efficacy and economic benefits of a modified Valsalva maneuver in patients with paroxysmal supraventricular tachycardia. World J Clin Cases 2020. [DOI: 10.12998/wjcc.v8.i23.5996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
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10
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Wang W, Jiang TF, Han WZ, Jin L, Zhao XJ, Guo Y. Efficacy and economic benefits of a modified Valsalva maneuver in patients with paroxysmal supraventricular tachycardia. World J Clin Cases 2020; 8:5999-6008. [PMID: 33344598 PMCID: PMC7723698 DOI: 10.12998/wjcc.v8.i23.5999] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 07/30/2020] [Accepted: 10/13/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND A modified Valsalva maneuver (VM) has been suggested to be superior to the standard VM for conversion of paroxysmal supraventricular tachycardia (PSVT).
AIM To evaluate the efficacy and economic benefits of a modified VM in Chinese patients.
METHODS Patients with PSVT admitted to our center between October 2017 and September 2019 were randomly assigned to the modified and standard VM groups. Conversion via VM was performed up to three times. The primary outcome of the study was the success rate of PSVT conversion to sinus rhythm. The secondary outcomes included the incidence of adverse events, economic cost during the visit, and the degree of patient acceptance of the treatment.
RESULTS Overall, 361 patients were enrolled, with 180 allocated to the modified VM group and 181 to the standard VM group. Baseline characteristics were well matched in the groups. Overall, the modified VM group had higher success rates of PSVT conversion after single (47.78% vs 15.38%, P < 0.001) and multiple (62.22% vs 19.78%, P < 0.001) VM sessions. No significant differences in the incidences of adverse events and rates of patient acceptance were detected between the two groups (both P > 0.05). Moreover, the economic cost of the clinic visit was significantly lower for the modified VM group than for the standard VM group (P < 0.05).
CONCLUSION The modified VM may confer both therapeutic and economic benefits as compared with the standard VM for conversion of PSVT.
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Affiliation(s)
- Wei Wang
- Internal Medicine-Cardiovascular Department, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, Shandong Province, China
| | - Teng-Fei Jiang
- Department of Nursing, The First Affiliated Hospital of Shandong First Medical University
| | - Wei-Zhong Han
- Internal Medicine-Cardiovascular Department, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, Shandong Province, China
| | - Lin Jin
- Internal Medicine-Cardiovascular Department, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, Shandong Province, China
| | - Xiao-Jing Zhao
- Internal Medicine-Cardiovascular Department, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, Shandong Province, China
| | - Ying Guo
- Department of Nursing, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, Shandong Province, China
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Ho SY. Anatomy of the Atrioventricular Junction, Atrioventricular Grooves, and Accessory Pathways. Card Electrophysiol Clin 2020; 12:437-445. [PMID: 33161994 DOI: 10.1016/j.ccep.2020.07.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Accessory pathways that bypass all or part of the normal atrioventricular conduction system traverse the atrioventricular junction. The atrioventricular junction comprises of a limited septal component and much more extensive right and left parietal components. Its composition forms a plane of insulation between atrial and ventricular myocardium, preventing direct continuity between them. Typical accessory atrioventricular pathways located anywhere along the atrioventricular junction are muscle bundles or may involve muscle around the walls of coronary sinus aneurysms or coronary veins. Increasingly, variants or unusual accessory pathways, some involving an accessory node, are reported in clinical studies.
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Affiliation(s)
- Siew Yen Ho
- Cardiac Morphology, Imperial College London, Royal Brompton & Harefield NHS Foundation Trust, London SW3 6NP, UK.
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Matta M, Marazzato J, De Ponti R, Gaita F, Anselmino M. Ablation of Accessory Pathways with Uncommon Electrophysiologic Properties. Card Electrophysiol Clin 2020; 12:567-581. [PMID: 33162004 DOI: 10.1016/j.ccep.2020.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
In rare cases, atrioventricular reentrant arrhythmias are sustained by accessory pathways with peculiar electrophysiologic features that may be related to their specific anatomy. Most of these bundles show decremental nodelike conduction properties and sustain peculiar forms of arrhythmias that require careful differential diagnosis. On the other hand, some pathways do not actively sustain any reentrant circuit and should nevertheless be promptly recognized to avoid unnecessary ablation attempts. Although rare, these variants of accessory pathway should be known to warrant a safe and effective catheter ablation procedure.
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Affiliation(s)
- Mario Matta
- Cardiology Division, Sant'Andrea Hospital, corso Mario Abbiate, 21, Vercelli 13100, Italy
| | - Jacopo Marazzato
- Department of Heart and Vessels, Ospedale di Circolo, Viale Borri, 57, Varese 21100, Italy; Department of Medicine and Surgery, University of Insubria, Viale Guicciardini, 9, Varese 21100, Italy
| | - Roberto De Ponti
- Department of Heart and Vessels, Ospedale di Circolo, Viale Borri, 57, Varese 21100, Italy; Department of Medicine and Surgery, University of Insubria, Viale Guicciardini, 9, Varese 21100, Italy
| | - Fiorenzo Gaita
- Cardiology Unit, J Medical Via Druento, 153/56, Turin 10151, Italy
| | - Matteo Anselmino
- Cardiology Division, Department of Medical Sciences, "Città della Salute e della Scienza di Torino" Hospital, University of Turin, Corso Bramante, 88, Turin 10126, Italy.
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Abstract
In some cases, atrioventricular reentrant arrhythmias are sustained by accessory pathways with peculiar electrophysiologic properties related to their specific anatomy. Most of these fibers, which may be responsible for variants of ventricular preexcitation, show decremental conduction properties due to a nodelike aspect or a peculiar tortuous anatomic route across the atrioventricular groove. Moreover, some fibers do not actively sustain any reentrant circuit and can be only involved as bystander in other arrhythmias. Although rare, these accessory pathway variants should be properly diagnosed using noninvasive and invasive methods to guide catheter ablation procedures when needed.
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Zhu C, Chen MX, Zhou GJ. Rare narrow QRS tachycardia with atrioventricular dissociation: A case report. World J Clin Cases 2020; 8:5420-5425. [PMID: 33269279 PMCID: PMC7674740 DOI: 10.12998/wjcc.v8.i21.5420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 09/05/2020] [Accepted: 09/22/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Most Mahaim fibers are right free-wall atriofascicular accessory pathways with only antegrade conduction. Concealed Mahaim fiber is not very rare; however, concealed nodoventricular fiber is a very rare kind of retrograde accessory pathway in supraventricular tachycardia with atrioventricular (AV) dissociation. Only a few cases about successful ablation of the nodoventricular accessory pathway have been reported. We describe the case of a 32-year-old woman who underwent an electrophysiology study and radiofrequency (RF) ablation of a rare narrow QRS tachycardia with AV dissociation.
CASE SUMMARY A 32-year-old woman with a history of paroxysmal palpitation was admitted to our hospital for RF ablation. Electrocardiography revealed a narrow QRS complex tachycardia with the same morphology in sinus rhythm. Echocardiography showed no structural heart disease. A right-sided concealed AV accessory pathway and a right-sided concealed nodoventricular accessory pathway were involved in the orthodromic atrioventricular reciprocating tachycardia. His bundle-ventricular interval during tachycardia was the same as that in sinus rhythm. The tachycardia could be initiated and entrained by ventricular pacing. Premature right ventricular stimulus introduced during the His-bundle refractory period when tachycardia occurred was able to advance the next atrial potential. The earliest atrial activation was mapped near the proximal slow AV nodal pathway. RF ablation of both accessary pathways was successfully performed under the guidance of a three-dimensional mapping system by recording the earliest retrograde atrial potential, and tachycardia could no longer be induced.
CONCLUSION Narrow QRS tachycardia with AV dissociation is inducible by concealed nodoventricular fiber and ablated by recording the earliest retrograde atrial potential.
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Affiliation(s)
- Chao Zhu
- Department of Cardiology, The Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou 225009, Jiangsu Province, China
| | - Ming-Xing Chen
- Department of Cardiology, The Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou 225009, Jiangsu Province, China
| | - Gui-Jian Zhou
- Department of Cardiology, The Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou 225009, Jiangsu Province, China
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Oesterle A, Lee AC, Voskoboinik A, Moss JD, Vedantham V, Walters TE, Lee BK, Tseng ZH, Gerstenfeld EP, Scheinman MM. Electrophysiologic approach to diagnosis and ablation of patients with permanent junctional reciprocating tachycardia associated with complex anatomy and/or physiology. J Cardiovasc Electrophysiol 2020; 31:3232-3242. [PMID: 33107135 DOI: 10.1111/jce.14788] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 10/04/2020] [Accepted: 10/11/2020] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Permanent junctional reciprocating tachycardia (PJRT) is a rare supraventricular tachycardia (SVT), typically involving a single decremental posteroseptal accessory pathway (AP). METHODS Four patients with long RP SVT underwent electrophysiology (EP) study and ablation. The cases were reviewed. RESULTS Case 1 recurred despite 3 prior ablations at the site of earliest retrograde atrial activation during orthodromic reciprocating tachycardia (ORT). Mapping during a repeat EP study demonstrated a prepotential in the coronary sinus (CS). Ablation over the earliest atrial activation in the CS resulted in dissociation of the potential from the atrium during sinus rhythm. The potential was traced back to the CS os and ablated. Case 2 underwent successful ablation at 6 o'clock on the mitral annulus (MA). ORT recurred and successful ablation was performed at 1 o'clock on the MA. Case 3 had tachycardia with variation in both V-A and A-H intervals which precluded the use of usual maneuvers so we used simultaneous atrial and ventricular pacing and introduced a premature atrial contraction with a closely coupled premature ventricular contraction. Case 4 had had two prior atrial fibrillation ablations with continued SVT over a decremental atrioventricular bypass tract that was successfully ablated at 5 o'clock on the tricuspid annulus. A second SVT consistent with a concealed nodoventricular pathway was successfully ablated at the right inferior extension of the AV nodal slow pathway. CONCLUSION We describe challenging cases of PJRT by virtue of complex anatomy, diagnostic features, and multiple arrhythmia mechanisms.
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Affiliation(s)
- Adam Oesterle
- Division of Cardiovascular Medicine, Department of Medicine, University of California Davis, Sacramento, California, USA
| | - Adam C Lee
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Aleksandr Voskoboinik
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Joshua D Moss
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Vasanth Vedantham
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Tomos E Walters
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Byron K Lee
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Zian H Tseng
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Edward P Gerstenfeld
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Melvin M Scheinman
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
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16
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Sekihara T, Nakano T, Yasuoka Y, Minamiguchi H. A case of typical and atypical atrioventricular nodal reentrant tachycardia with a bystander nodoventricular pathway diagnosed based on the findings during early ventricular premature contractions. HeartRhythm Case Rep 2020; 6:680-684. [PMID: 33101931 PMCID: PMC7573364 DOI: 10.1016/j.hrcr.2020.06.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Takayuki Sekihara
- Cardiovascular Division, Osaka-Minami Medical Center, National Hospital Organization, Kawachi-nagano, Japan
| | - Tomoaki Nakano
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yoshinori Yasuoka
- Cardiovascular Division, Osaka-Minami Medical Center, National Hospital Organization, Kawachi-nagano, Japan
| | - Hitoshi Minamiguchi
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
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17
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18
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The various manifestations of concealed nodofascicular/nodoventricular bypass tracts. Heart Rhythm 2020; 17:1280-1290. [DOI: 10.1016/j.hrthm.2020.03.026] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 03/29/2020] [Indexed: 12/24/2022]
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19
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Cardona-Guarache R, Han FT, Nguyen DT, Chicos AB, Badhwar N, Knight BP, Johnson CJ, Heaven D, Scheinman MM. Ablation of Supraventricular Tachycardias From Concealed Left-Sided Nodoventricular and Nodofascicular Accessory Pathways. Circ Arrhythm Electrophysiol 2020; 13:e007853. [DOI: 10.1161/circep.119.007853] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Nodoventricular and nodofascicular accessory pathways (AP) are uncommon connections between the atrioventricular node and the fascicles or ventricles.
Methods:
Five patients with nodofascicular or nodoventricular tachycardia were studied.
Results:
We identified 5 patients with concealed, left-sided nodoventricular (n=4), and nodofascicular (n=1) AP. We proved the participation of AP in tachycardia by delivering His-synchronous premature ventricular contractions that either delayed the subsequent atrial electrogram or terminated the tachycardia (n=3), and by observing an increase in VA interval coincident with left bundle branch block (n=2). The APs were not atrioventricular pathways because the septal VA interval during tachycardia was <70 ms in 3, 1 had spontaneous atrioventricular dissociation, and in 1 the atria were dissociated from the circuit with atrial overdrive pacing. Entrainment from the right ventricle showed ventricular fusion in 4 out of 5 cases. A left-sided origin of the AP was suspected after failed ablation of the right inferior extension of atrioventricular node in 3 cases and by observing a VA increase with left bundle branch block in 2 cases. The nodofascicular and 3 of the nodoventricular AP were successfully ablated from within the proximal coronary sinus (CS) guided by recorded potentials at the roof of the CS, and 1 nodoventricular AP was ablated via a transseptal approach near the CS os.
Conclusions:
Left-sided nodofascicular and nodoventricular AP appear to connect the ventricles with the CS musculature in the region of the CS os. Mapping and successful ablation sites can be guided by recording potentials within or near the CS os.
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Affiliation(s)
- Ricardo Cardona-Guarache
- Division of Cardiology, University of California San Francisco, San Francisco, CA (R.C.-G., M.M.S.)
| | - Frederick T. Han
- Division of Cardiology, University of California San Diego, La Jolla (F.T.H.)
| | - Duy T. Nguyen
- Division of Cardiology, Stanford University, Palo Alto, CA (D.T.N., N.B.)
| | - Alexandru B. Chicos
- Division of Cardiology, Northwestern University, Chicago, IL (A.B.C., B.P.K.)
| | - Nitish Badhwar
- Division of Cardiology, Stanford University, Palo Alto, CA (D.T.N., N.B.)
| | - Bradley P. Knight
- Division of Cardiology, Northwestern University, Chicago, IL (A.B.C., B.P.K.)
| | | | - David Heaven
- Division of Cardiology, Middlemore Hospital, Auckland, NZ (D.H.)
| | - Melvin M. Scheinman
- Division of Cardiology, University of California San Francisco, San Francisco, CA (R.C.-G., M.M.S.)
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20
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Ortman M, Collins JA, Spivack T, Ho RT. An unusual supraventricular tachycardia with discrepant findings: What is the mechanism? Heart Rhythm 2020; 17:669-671. [DOI: 10.1016/j.hrthm.2019.12.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Indexed: 11/26/2022]
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21
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Brugada J, Katritsis DG, Arbelo E, Arribas F, Bax JJ, Blomström-Lundqvist C, Calkins H, Corrado D, Deftereos SG, Diller GP, Gomez-Doblas JJ, Gorenek B, Grace A, Ho SY, Kaski JC, Kuck KH, Lambiase PD, Sacher F, Sarquella-Brugada G, Suwalski P, Zaza A. 2019 ESC Guidelines for the management of patients with supraventricular tachycardiaThe Task Force for the management of patients with supraventricular tachycardia of the European Society of Cardiology (ESC). Eur Heart J 2020; 41:655-720. [PMID: 31504425 DOI: 10.1093/eurheartj/ehz467] [Citation(s) in RCA: 615] [Impact Index Per Article: 123.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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22
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Kara M, Korkmaz A, Karimli E, Simsek E, Ozeke O, Cay S, Ozcan F, Aras D, Topaloglu S. A narrow QRS complex during a left bundle branch block morphology wide QRS tachycardia: A clue for manifest or bystander involvement of nodofascicular pathway? J Cardiovasc Electrophysiol 2020; 31:552-556. [PMID: 31916620 DOI: 10.1111/jce.14343] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 12/19/2019] [Accepted: 12/23/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Meryem Kara
- Department of Cardiology, Ankara City Hospital, Health Sciences University, Ankara, Turkey
| | - Ahmet Korkmaz
- Department of Cardiology, Ankara City Hospital, Health Sciences University, Ankara, Turkey
| | - Emin Karimli
- Department of Cardiology, Ankara City Hospital, Health Sciences University, Ankara, Turkey
| | - Evrim Simsek
- Department of Cardiology, Ankara City Hospital, Health Sciences University, Ankara, Turkey.,Department of Cardiology, Ege University, İzmir, Turkey
| | - Ozcan Ozeke
- Department of Cardiology, Ankara City Hospital, Health Sciences University, Ankara, Turkey
| | - Serkan Cay
- Department of Cardiology, Ankara City Hospital, Health Sciences University, Ankara, Turkey
| | - Firat Ozcan
- Department of Cardiology, Ankara City Hospital, Health Sciences University, Ankara, Turkey
| | - Dursun Aras
- Department of Cardiology, Ankara City Hospital, Health Sciences University, Ankara, Turkey
| | - Serkan Topaloglu
- Department of Cardiology, Ankara City Hospital, Health Sciences University, Ankara, Turkey
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23
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Hoffmayer KS, Han FT, Singh D, Scheinman MM. Variants of accessory pathways. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2020; 43:21-29. [DOI: 10.1111/pace.13830] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 09/25/2019] [Accepted: 10/19/2019] [Indexed: 12/19/2022]
Affiliation(s)
- Kurt S. Hoffmayer
- Division of CardiologySection of ElectrophysiologyUniversity of California San Diego California
| | - Frederick T. Han
- Division of CardiologySection of ElectrophysiologyUniversity of California San Diego California
| | - David Singh
- Department of Cardiovascular DiseasesQueens Medical Center Honolulu Hawaii
| | - Melvin M. Scheinman
- Division of CardiologySection of ElectrophysiologyUniversity of California San Francisco California
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24
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Wakamatsu Y, Nagashima K, Watanabe R, Arai M, Otsuka N, Yagyu S, Kurokawa S, Ohkubo K, Nakai T, Okumura Y. Novel V-V-A response after right ventricular entrainment pacing for narrow QRS tachycardia: What is the mechanism? J Cardiovasc Electrophysiol 2019; 30:2528-2530. [PMID: 31433092 DOI: 10.1111/jce.14131] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 08/14/2019] [Accepted: 08/16/2019] [Indexed: 12/28/2022]
Affiliation(s)
- Yuji Wakamatsu
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Koichi Nagashima
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Ryuta Watanabe
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Masaru Arai
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Naoto Otsuka
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Seina Yagyu
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Sayaka Kurokawa
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Kimie Ohkubo
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Toshiko Nakai
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
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25
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Sahin M, Ozeke O, Cay S, Ozcan F, Karimli E, Kara M, Topaloglu S, Aras D. An uncommon response to a His refractory premature ventricular complex during a short RP supraventricular tachycardia: What is the mechanism? PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2019; 42:1050-1053. [DOI: 10.1111/pace.13719] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 04/27/2019] [Accepted: 05/03/2019] [Indexed: 12/27/2022]
Affiliation(s)
- Mursel Sahin
- Department of CardiologyAnkara City Hospital, Health Sciences University Ankara Turkey
- Department of CardiologyKaradeniz Technical University Trabzon Turkey
| | - Ozcan Ozeke
- Department of CardiologyAnkara City Hospital, Health Sciences University Ankara Turkey
| | - Serkan Cay
- Department of CardiologyAnkara City Hospital, Health Sciences University Ankara Turkey
| | - Firat Ozcan
- Department of CardiologyAnkara City Hospital, Health Sciences University Ankara Turkey
| | - Emin Karimli
- Department of CardiologyAnkara City Hospital, Health Sciences University Ankara Turkey
| | - Meryem Kara
- Department of CardiologyAnkara City Hospital, Health Sciences University Ankara Turkey
| | - Serkan Topaloglu
- Department of CardiologyAnkara City Hospital, Health Sciences University Ankara Turkey
| | - Dursun Aras
- Department of CardiologyAnkara City Hospital, Health Sciences University Ankara Turkey
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26
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Bradfield JS, Fujimura O, Boyle NG, Shivkumar K. Catheter ablation in the vicinity of the proximal conduction system: Your eyes cannot see what your mind does not know. Heart Rhythm 2019; 16:378-379. [PMID: 30630100 DOI: 10.1016/j.hrthm.2019.01.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Indexed: 11/16/2022]
Affiliation(s)
- Jason S Bradfield
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center, David Geffen School of Medicine, UCLA Health System, Los Angeles, California
| | - Osamu Fujimura
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center, David Geffen School of Medicine, UCLA Health System, Los Angeles, California
| | - Noel G Boyle
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center, David Geffen School of Medicine, UCLA Health System, Los Angeles, California
| | - Kalyanam Shivkumar
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center, David Geffen School of Medicine, UCLA Health System, Los Angeles, California.
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