manifest parahisian accessory pathway (wpw) ablation our experience
DESCRIPTION
ECRA 2013 ( EGYPTIAN Cardiac Rhythm Association 2013 conference ... cardiac electrophysiology experience in ablation of parahisian accessory pathway using Radiofrequency ablationTRANSCRIPT
Manifest para-Hisian accessory Pathway (WPW)
ablation Dr. Ahmed Taha Hussein
M.Sc.cardiologyAssistant lecturer of cardiology, EPS
Zagazig university, EGYPT
ECRA 2013 - EGYPTECRA 2013 - EGYPT
Our EPSEPS team
History
Male pt. 16 years old with irrelevant medical or family history .
Gives history of recurrent attacks of palpitation mostly of rapid regular pattern , but sometimes irregular since he was 9 years old .
His parents also reported recurrent attacks of syncope for few minutes.
3 month ago , he developed syncope in the street, the witness reported that the ambulance paramedics gave him DC shock .
Past medical History
The patient underwent EP-Study 2009 , because of documented SVT , was thought to be ( AVNRT ) according to his event ECG.
Post operative report : ablation of slow Pathway with lost AH jump , but with trial of induction of tachycardia , he developed wide QRS tachycardia , deduced to be AVRT using incessant AP , but they failed to ablate , giving hint that the AP may be postro-septal .
Physical examination
Was unremarkable except for :He Looks very tall relative to his age ( >2
SD ), with high arched palate , and malleable joints.
His cardiac examination , revealed MR of grade I/IV .
Marfan like picture .
Echocardiography
Normal LV function and internal dimensions.
Dilated aortic root AoR=43 mm . 1st degree Mitral valve prolapse with trivial
eccentric MR. Normal PAP , and right side of the heart.LAB investigations were totally normal .
ECG before procedure WPW : overt AP, short PR , wide QRS , delta wave. Location : parahissian Vs antroseptal AP : +ve delta in I,II ,III , avF V3-V6 ------ve avL , avR , V1
ECG
ECG before procedure WPW : overt AP, short PR , wide QRS , delta wave. Location : parahissian Vs antroseptal AP : +ve delta in I,II ,III , avF V3-V6 ------ve avL , avR , V1,V2
ECG –orthodromic AVRT
HOLTER study
Recurrent Attacks of Narrow QRS tachycardia mostly orthodromic AVRT
Intermittent WPW ( delta + short PR +wide QRS ).
Atrial fibrillation . Wide QRS tachycardia mostly Antridromic
AVRT.
Narrow QRS variable RR , absent P-wave tachycardia AF
Intermittent pre-excitation
Pre-excited AF
EP-LAB
consent was taken and informed about the complication of the procedure .
Briefly, 2 quadri-polar catheters were introduced through right femoral veins and left subclavian deca-polar and placed respectively in His bundle region, right ventricle, coronary sinus (CS), and ablation 4mm for mapping and ablation.
A H’V
Fluoroscopic views
LAORAO
ABL
Atrial pacing
AV
Narrowest AV in HISS record with no H potential
Antidromic AVRT with very short VA time with early V at Hiss record
V A
AV=40ms
A V
RF=20J for 10 sec
Junctional Rhythm
RF
During successful ablation : Delta disappeared and AV time normalize
RF
RF=20J for 30 sec
During successful ablation of APDelta disappeared and PR interval normalize
Post ablation
AH=100ms
Atrial pacing
ECG post procedure
Post ablation testing
Programmed Burst ,decremental, extra-stimulation of Atrial and ventricular pacing to test the conductivity of the AP , revealed no conduction( block) in either directions (antegrade & retrograde), and no tachycardia was induced .
Concentric conduction ,through AVN reaching wenchbach point with 500/260 ms.
Normal intact AVN conduction. Differential ventricular pacing to test AP
conductivity revealed block.
Follow UP
3 month later holter study done :No arrhythmia detected either of narrow or
wide QRS .Normal Sinus rhythm , normal PR
interval , narrow QRS complex.
Take home message Surface ECG has low specificity in accurate localization
of septal Accessory pathways , and EPS is mandatory for accurate localization of septal APs.
Septal APs have special behavior of “pathway slant “pathway slant ” ” which needed to be taken in consideration when ablating to avoid collateral damage.
EPS not only to confirm AVRT, but needed to exclude other type of arrhythmia may be coincidental.
AF associated with WPW found to vanish with successful AP ablation in 90% of cases.
Although AP may be localized in potentially dangerous areas, no serious complication occur if AP potential is accurately identified and recorded representing the optimal ablation target .
Thank youThank you
نوصل يوم في لبد
نحلم بس .!!