Variable Presentations and Ablation Sites for Manifest Nodoventricular/Nodofascicular Fibers

Babak Nazer, Tomos E. Walters, Thomas Dewland, Aditi Naniwadekar, Jacob S. Koruth, Mohammed Najeeb Osman, Anselma Intini, Minglong Chen, Jurgen Biermann, Johannes Steinfurt, Jonathan M. Kalman, Ronn E. Tanel, Byron K. Lee, Nitish Badhwar, Edward P. Gerstenfeld, Melvin M. Scheinman

Research output: Contribution to journalArticle

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Abstract

BACKGROUND: Nodofascicular and nodoventricular (NFV) accessory pathways connect the atrioventricular node and the Purkinje system or ventricular myocardium, respectively. Concealed NFV pathways participate as the retrograde limb of supraventricular tachycardia (SVT). Manifest NFV pathways can comprise the anterograde limb of wide-complex SVT but are quite rare. The purpose of this report is to highlight the electrophysiological properties and sites of ablation for manifest NFV pathways. METHODS: Eight patients underwent electrophysiology studies for wide-complex tachycardia (3), for narrow-complex tachycardia (1), and preexcitation (4). RESULTS: NFV was an integral part of the SVT circuit in 3 patients. Cases 1 to 2 were wide-complex tachycardia because of manifest NFV SVT. Case 3 was a bidirectional NFV that conducted retrograde during concealed NFV SVT and anterograde causing preexcitation during atrial pacing. NFV was a bystander during atrioventricular node re-entrant tachycardia, atrial fibrillation, atrial flutter, and orthodromic atrioventricular re-entrant tachycardia in 4 cases and caused only preexcitation in 1. Successful NFV ablation was achieved empirically in the slow pathway region in 1 case. In 5 cases, the ventricular insertion was mapped to the slow pathway region (2 cases) or septal right ventricle (3 cases). The NFV was not mapped in cases 5 and 7 because of its bystander role. QRS morphology of preexcitation predicted the right ventricle insertion sites in 4 of the 5 cases in which it was mapped. During follow-up, 1 patient noted recurrent palpitations but no documented SVT. CONCLUSIONS: Manifest NFV may be critical for wide-complex tachycardia/manifest NFV SVT, act as the retrograde limb for narrow-complex tachycardia/concealed NFV SVT, or cause bystander preexcitation. Ablation should initially target the slow pathway region, with mapping of the right ventricle insertion site if slow pathway ablation is not successful. The QRS morphology of maximal preexcitation may be helpful in predicting successful right ventricle ablation site.

Original languageEnglish (US)
Pages (from-to)e007337
JournalCirculation. Arrhythmia and electrophysiology
Volume12
Issue number9
DOIs
StatePublished - Sep 1 2019

Fingerprint

Supraventricular Tachycardia
Tachycardia
Heart Ventricles
Atrioventricular Node
Extremities
Accessory Atrioventricular Bundle
Atrial Flutter
Electrophysiology
Atrial Fibrillation
Myocardium

Keywords

  • atrioventricular node
  • electrophysiology
  • myocardium
  • tachycardia, supraventricular
  • Wolff-Parkinson-White syndrome

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Physiology (medical)

Cite this

Variable Presentations and Ablation Sites for Manifest Nodoventricular/Nodofascicular Fibers. / Nazer, Babak; Walters, Tomos E.; Dewland, Thomas; Naniwadekar, Aditi; Koruth, Jacob S.; Najeeb Osman, Mohammed; Intini, Anselma; Chen, Minglong; Biermann, Jurgen; Steinfurt, Johannes; Kalman, Jonathan M.; Tanel, Ronn E.; Lee, Byron K.; Badhwar, Nitish; Gerstenfeld, Edward P.; Scheinman, Melvin M.

In: Circulation. Arrhythmia and electrophysiology, Vol. 12, No. 9, 01.09.2019, p. e007337.

Research output: Contribution to journalArticle

Nazer, B, Walters, TE, Dewland, T, Naniwadekar, A, Koruth, JS, Najeeb Osman, M, Intini, A, Chen, M, Biermann, J, Steinfurt, J, Kalman, JM, Tanel, RE, Lee, BK, Badhwar, N, Gerstenfeld, EP & Scheinman, MM 2019, 'Variable Presentations and Ablation Sites for Manifest Nodoventricular/Nodofascicular Fibers', Circulation. Arrhythmia and electrophysiology, vol. 12, no. 9, pp. e007337. https://doi.org/10.1161/CIRCEP.119.007337
Nazer, Babak ; Walters, Tomos E. ; Dewland, Thomas ; Naniwadekar, Aditi ; Koruth, Jacob S. ; Najeeb Osman, Mohammed ; Intini, Anselma ; Chen, Minglong ; Biermann, Jurgen ; Steinfurt, Johannes ; Kalman, Jonathan M. ; Tanel, Ronn E. ; Lee, Byron K. ; Badhwar, Nitish ; Gerstenfeld, Edward P. ; Scheinman, Melvin M. / Variable Presentations and Ablation Sites for Manifest Nodoventricular/Nodofascicular Fibers. In: Circulation. Arrhythmia and electrophysiology. 2019 ; Vol. 12, No. 9. pp. e007337.
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T1 - Variable Presentations and Ablation Sites for Manifest Nodoventricular/Nodofascicular Fibers

AU - Nazer, Babak

AU - Walters, Tomos E.

AU - Dewland, Thomas

AU - Naniwadekar, Aditi

AU - Koruth, Jacob S.

AU - Najeeb Osman, Mohammed

AU - Intini, Anselma

AU - Chen, Minglong

AU - Biermann, Jurgen

AU - Steinfurt, Johannes

AU - Kalman, Jonathan M.

AU - Tanel, Ronn E.

AU - Lee, Byron K.

AU - Badhwar, Nitish

AU - Gerstenfeld, Edward P.

AU - Scheinman, Melvin M.

PY - 2019/9/1

Y1 - 2019/9/1

N2 - BACKGROUND: Nodofascicular and nodoventricular (NFV) accessory pathways connect the atrioventricular node and the Purkinje system or ventricular myocardium, respectively. Concealed NFV pathways participate as the retrograde limb of supraventricular tachycardia (SVT). Manifest NFV pathways can comprise the anterograde limb of wide-complex SVT but are quite rare. The purpose of this report is to highlight the electrophysiological properties and sites of ablation for manifest NFV pathways. METHODS: Eight patients underwent electrophysiology studies for wide-complex tachycardia (3), for narrow-complex tachycardia (1), and preexcitation (4). RESULTS: NFV was an integral part of the SVT circuit in 3 patients. Cases 1 to 2 were wide-complex tachycardia because of manifest NFV SVT. Case 3 was a bidirectional NFV that conducted retrograde during concealed NFV SVT and anterograde causing preexcitation during atrial pacing. NFV was a bystander during atrioventricular node re-entrant tachycardia, atrial fibrillation, atrial flutter, and orthodromic atrioventricular re-entrant tachycardia in 4 cases and caused only preexcitation in 1. Successful NFV ablation was achieved empirically in the slow pathway region in 1 case. In 5 cases, the ventricular insertion was mapped to the slow pathway region (2 cases) or septal right ventricle (3 cases). The NFV was not mapped in cases 5 and 7 because of its bystander role. QRS morphology of preexcitation predicted the right ventricle insertion sites in 4 of the 5 cases in which it was mapped. During follow-up, 1 patient noted recurrent palpitations but no documented SVT. CONCLUSIONS: Manifest NFV may be critical for wide-complex tachycardia/manifest NFV SVT, act as the retrograde limb for narrow-complex tachycardia/concealed NFV SVT, or cause bystander preexcitation. Ablation should initially target the slow pathway region, with mapping of the right ventricle insertion site if slow pathway ablation is not successful. The QRS morphology of maximal preexcitation may be helpful in predicting successful right ventricle ablation site.

AB - BACKGROUND: Nodofascicular and nodoventricular (NFV) accessory pathways connect the atrioventricular node and the Purkinje system or ventricular myocardium, respectively. Concealed NFV pathways participate as the retrograde limb of supraventricular tachycardia (SVT). Manifest NFV pathways can comprise the anterograde limb of wide-complex SVT but are quite rare. The purpose of this report is to highlight the electrophysiological properties and sites of ablation for manifest NFV pathways. METHODS: Eight patients underwent electrophysiology studies for wide-complex tachycardia (3), for narrow-complex tachycardia (1), and preexcitation (4). RESULTS: NFV was an integral part of the SVT circuit in 3 patients. Cases 1 to 2 were wide-complex tachycardia because of manifest NFV SVT. Case 3 was a bidirectional NFV that conducted retrograde during concealed NFV SVT and anterograde causing preexcitation during atrial pacing. NFV was a bystander during atrioventricular node re-entrant tachycardia, atrial fibrillation, atrial flutter, and orthodromic atrioventricular re-entrant tachycardia in 4 cases and caused only preexcitation in 1. Successful NFV ablation was achieved empirically in the slow pathway region in 1 case. In 5 cases, the ventricular insertion was mapped to the slow pathway region (2 cases) or septal right ventricle (3 cases). The NFV was not mapped in cases 5 and 7 because of its bystander role. QRS morphology of preexcitation predicted the right ventricle insertion sites in 4 of the 5 cases in which it was mapped. During follow-up, 1 patient noted recurrent palpitations but no documented SVT. CONCLUSIONS: Manifest NFV may be critical for wide-complex tachycardia/manifest NFV SVT, act as the retrograde limb for narrow-complex tachycardia/concealed NFV SVT, or cause bystander preexcitation. Ablation should initially target the slow pathway region, with mapping of the right ventricle insertion site if slow pathway ablation is not successful. The QRS morphology of maximal preexcitation may be helpful in predicting successful right ventricle ablation site.

KW - atrioventricular node

KW - electrophysiology

KW - myocardium

KW - tachycardia, supraventricular

KW - Wolff-Parkinson-White syndrome

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