A middle aged female with PSVT

Raja Selvaraj, JIPMER

Learning

  • Hear - Forget
  • See - Remember (Visual)
  • Do - Understand (active participation)
  • Think - Learn (answer questions)

Edgar Dale's cone of learning

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Socratic method

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Presentation

  • Middle aged female
  • Episodic palpitations
  • Documented narrow QRS tachycardia

Baseline measurements

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Ventricular pacing

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Posterior AV nodal extensions

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Inoue S, Becker AE. Posterior extensions of the human compact atrioventricular node: a neglected anatomic feature of potential clinical significance. Circulation. 1998;97(2):188–193

Ventricular extrastimulus

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Double potentials in the coronary sinus

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AKIYAMA et al. Coronary Sinus Recordings of Double Potentials Associated with Retrograde Conduction Through Left Atrioventricular Accessory Pathways. JCE 2004, 15: 1371–1376. doi:10.1046/j.1540-8167.2004.04422.x

Double potentials in the coronary sinus

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Atrial extrastimulus

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Ventricular burst pacing

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Ventricular overdrive - Beginning

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Ventricular extra

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PVC by coupling interval

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Summarise so far

  • Regular NQRST
  • Central atrial activation, VA 70
  • VOP terminates
  • His refractory PVCs dont preexcite
  • What next?

Parahisian

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Parahisian pacing in a Posteroseptal AP

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Measurement of the ventriculoatrial interval from the coronary sinus during para-Hisian pacing may fail to distinguish ventriculoatrial nodal conduction from conduction over a septal accessory pathway. Iijima, Takafumi et al. Journal of Arrhythmia , Volume 31 , Issue 1 , 33 - 37

Ventricular overdrive Isoprenaline

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Where are we ?

  • Parahisian confirms presence of concealed AP
  • VOP confirms AVRT
  • What approach to map?

Where do you want to map

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Delta VA

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Chiang CE, Chen SA, Tai CT, Wu TJ, Lee SH, Cheng CC, Chiou CW, Ueng KC, Wen ZC, Chang MS. Prediction of successful ablation site of concealed posteroseptal accessory pathways by a novel algorithm using baseline electrophysiological parameters: implication for an abbreviated ablation procedure. Circulation. 1996 Mar 1;93(5):982-91. PubMed PMID: 8598090.

Sequence of potentials in CS

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PAP, R., TRAYKOV, V. B., MAKAI, A., BENCSIK, G., FORSTER, T. and SÁGHY, L. (2008), Ablation of Posteroseptal and Left Posterior Accessory Pathways Guided by Left Atrium–Coronary Sinus Musculature Activation Sequence. Journal of Cardiovascular Electrophysiology, 19: 653–658. doi:10.1111/j.1540-8167.2008.01103.x

Where do you want to map

03_v_extra.jpg

CS-LV connections

  • 480 patients with posteroseptal / left posterior APs
  • CSAP in 171
  • CS diverticulum in 36
  • Fusiform enlargement of a tributary in 15
  • Normal in others

Coronary Sinus-Ventricular Accessory Connections Producing Posteroseptal and Left Posterior Accessory Pathways Incidence and Electrophysiological Identification. Sun, Arruda, … Jackman. Circulation. 2002;106:1362-1367

CSAP with normal CS

  • MCV in 82%
  • PCV in 11%
  • Both in 5%
  • Floor between both in 2%

Coronary Sinus-Ventricular Accessory Connections Producing Posteroseptal and Left Posterior Accessory Pathways Incidence and Electrophysiological Identification. Sun, Arruda, … Jackman. Circulation. 2002;106:1362-1367

CS venogram

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Successful site

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Signal within MCV

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Successful ablation

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Post ablation

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What did you learn today ?