BACKGROUND The various arrhythmic manifestations of concealed nodofascicular (NF)/nodoventricular (NV) bypass tracts (BPTs) are poorly understood. OBJECTIVE The purpose of the study was to define diagnostic criteria for supraventricular tachycardias (SVTs) associated with concealed nodal pathways (NPs). METHODS We reviewed 11 patients with concealed NPs who underwent electrophysiology study and ablation for symptomatic SVT. RESULTS Of 11 patients 7 (64% women; mean age 54 +/- 16 years), NF/NV BPTs were active bystanders during atrioventricular nodal reentrant tachycardia (atypical [n = 4]; typical [n = 2]) or participants during orthodromic NF/NV reentrant tachycardia (n = 5). The majority (10 of 11 [91%]) had nodal origin in the slow pathway (SP) and 7 of 11 (64%) presented as long RP SVT. Ablation of the SP targeting the right (n = 10) or left (n = 1) inferior extension eliminated concealed NP-associated SVTs in all patients. CONCLUSION Concealed NF/NV BPTs are active bystanders equally as common as participants during SVT. They typically insert into the SP and often present as long RP SVT. SP ablation eliminates concealed NF/NV BPT-associated SVTs regardless of the mechanism.
Introduction It is routine practice to observe patients (pts) overnight in the hospital after atrial fibrillation (AF) ablation. We report single center experience comparing the rate of complications prior to and after implementing a strategy of same day discharge (SDD) following AF ablation. Objective To assess the safety of SDD after AF ablation. Methods We reviewed the charts of consecutive pts who underwent AF ablation between Jan 2005 to Dec 2015. Patients who were electively admitted to undergo AF ablation or left atrial flutter ablation (AFL) were included. Patients undergoing only right atrial flutter ablation and in-patients were excluded. In Sept 2012 SDD strategy was implemented. Complication rates were collected up to 3 months post ablation. Major complications were defined as death, pericardial tamponade, CVA, hematoma requiring intervention, pulmonary vein stenosis, diaphragmatic paralysis or atrioesophageal fistula formation. Minor complications were defined as hematoma not requiring intervention and procedure related readmissions. Comparisons were made using an intention to treat analysis. Results Group A (between Jan 2005 to Feb 2010) included 145 patients (87 males; 60.2 yrs mean age; 103 paroxysmal AF) who were observed overnight. Group B (between Mar 2010 to Dec 2015) included 426 patients (298 males; 62.3 yrs mean age; 247 paroxysmal AF) undergoing ablation following implementation of the SDD strategy. Patients in Group B were contacted by phone next day. In Group B, 51/426 (12%) pts were not discharged same day due to non-ablation related medical care (15/50 pts), ablation related complications (17/50 pts), pt preference (14/50 pts) and late cases (5/50 pts). Rate of total complications was more frequent in Group A (Group A 11.7% vs Group B 4.4%; p 0.026). Major complications happened in 2 pts in Group A and 6 pts in Group B. None of the major complications in Group B happened within 24 hrs of discharge. Only one pt in Group B had pericardial effusion drained 10 days post procedure. Most common minor complication in Group A was hematoma not requiring intervention and Group B was procedure related readmissions. Conclusions Our data suggest that SDD after AF or AFL ablation can be safely implemented in majority of pts with similar outcomes as pts observed overnight.
Background—Diagnosing atypical atrioventricular node-dependent long RP supraventricular tachycardias (SVTs) can be challenging. Methods and Results—Nineteen patients with 20 SVTs (atypical atrioventricular nodal reentrant tachycardia without [n=11]/with [n=3] a bystander nodofascicular [NF] accessory pathway, orthodromic reciprocating tachycardia [ORT] using a decremental atrioventricular [permanent form of junctional reciprocating tachycardia; n=4] or NF [NF reentrant tachycardia; n=2]) accessory pathway underwent electrophysiological study. Postpacing interval (PPI)–tachycardia cycle length (TCL), corrected PPI, [INCREMENT]VA (ventriculoatrial), [INCREMENT]HA (His-atrial), [INCREMENT]AH (atrio-His) values, and responses to His-refractory ventricular premature depolarizations were studied. Compared with atrioventricular nodal reentrant tachycardia, ORT patients were younger (42±13 years versus 54±19 years; P=0.036) and were women (5/6 [83%] versus 3/14 [21%]; P=0.036); TCLs were similar (435 ms versus 429 ms; 95% confidence interval, −47.5 to 35.5). PPI–TCL was shorter for ORT (118 ms versus 176 ms; 95% confidence interval, 26.3–89.7) but only 50% had PPI–TCL <115 ms, whereas 5 of 6 (83%) had PPI–TCL <125 ms (sensitivity, 83%; specificity, 100%). Corrected PPI <110 ms, [INCREMENT]VA <85 ms, and [INCREMENT]HA <0 ms had equivalent sensitivity (67%) and 100% specificity for ORT. Compared with permanent form of junctional reciprocating tachycardia, NF reentrant tachycardia/atrioventricular nodal reentrant tachycardia had longer [INCREMENT]AH (29 ms versus 10 ms; 95% confidence interval, 3.03–35.0) or AH(SVT)<AH(NSR) (normal sinus rhythm) His-refractory ventricular premature depolarizations advanced (4/8 [50%]), delayed (4/8 [50%]), or terminated (5/8 [63%]) SVT in all accessory pathway patients. Conclusions—This unusual SVT requires separate maneuvers to delineate its upper and lower circuit. Standard entrainment criteria are modestly sensitive but highly specific for ORT; and PPI–TCL of 125 ms seems better than 115 ms. The [INCREMENT]AH criteria, or paradoxically AH(SVT)<AH(NSR), differentiates NF reentrant tachycardia/atrioventricular nodal reentrant tachycardia from permanent form of junctional reciprocating tachycardia. Bystander accessory pathways were only identified by His-refractory ventricular premature depolarizations.
With recent advances in implantable cardioverter de brillator (ICD) technology resulting in smaller devices and better leads, ICD implant rates have been increasing dramatically.1 Almost every study that has assessed the role of an ICD has concluded that the devices improve survival, whether they are used for secondary prevention (after successful resuscitation from a life-threatening arrhythmia2 -4) or for primary prevention of sudden death (in patients deemed to be at high risk of arrhythmic sudden death5 -7). In this light, it seems iconoclastic to even contemplate not implanting an ICD in a patient with documented ventricular tachycardia (VT) and structural heart disease. However, it is important to examine the available data carefully and determine whether ICD implantation has been shown to afford a survival bene t in all patients with VT. Speci cally, do patients with slow, stable VT derive a survival advantage from ICD implantation?
