dtruelson
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Conclusion
· Wolff-Parkinson-White syndrome with multiple pathways
○ Elevated-risk features for malignant arrhythmia
○ Orthodromic AV reentry tachycardia echo beats under anesthesia
○ Accessory pathway #1: left anterior
§ Successful uncomplicated radiofrequency ablation
○ Accessory pathway #2: left anterolateral
§ Successful uncomplicated radiofrequency ablation
○ Accessory pathway #3: left posteroseptal
§ Transient mechanical suppression with mapping in proximal coronary sinus
§ Lasting mechanical suppression with mapping in left atrium
§ Empiric radiofrequency ablation in left posteroseptal area
· Possible subtle preexcitation noted in recovery room
○ Physiologic first-/second-degree block with adenosine
· Normal AV node function post ablation
· Zero-radiation procedure
Procedure Comments
Procedure Comments 9 y.o. with chromosome 15q microduplication and Wolff-Parkinson-White syndrome with history of SVT in infancy, lately asymptomatic, with possible multiple delta wave morphologies on serial ECGs, presenting for EP study and ablation for prevention of sudden death.
ANESTHESIA FOR EPS/RFA. Inhalational anesthetic agents and/or propofol and endotracheal intubation were used. Please see the anesthesia record for details.
VASCULAR ACCESS. The sites were prepared in the usual sterile fashion with chlorhexidine gluconate. The areas were draped. Local anesthesia (lidocaine and/or bupivicaine) was infiltrated in the access areas before and/or during and/or after the procedure, as indicated, see log. Vascular access was achieved percutaneously with multiple sheaths for catheter placement and medication infusion; sheaths were upsized as needed during the procedure, ultimately including: 8.5 Fr RFV, 5+4 Fr LFV.
3D MAPPING ENSITE NAVX: 3D mapping was performed using the St Jude NavX Precision system for electroanatomic mapping and fluoroscopy reduction during the procedure.
FLUOROSCOPY, EPS/RFA: Digital pulsed fluoroscopy with the lowest possible exposure considering many factors using multple angulations was available to manuever the intracardiac catheters.
TRANSSEPTAL PUNCTURE: A transseptal puncture was performed to map the LA and/or LV and catheter ablation. This was performed using electroanatomic mapping and transthoracic echo due to unexpected unavailability of transesophageal echo probe for processing reasons. The fossa had been readily identified with catheter manipulation and tagged on NavX. The Baylis needle was observed on NavX to drop and engage the fossa, after which position was confirmed with subcostal imaging prior to puncture.
EP STUDY AND ABLATION: See log. Atrial fibrillation was difficult to induce but during rapid pacing and short periods of atrial fibrillation, there were at least two and probably three preexcited morphologies with rapid conduction (SPERRI <260 msec under general anesthesia) via at least two morphologies.
SHEATHS PULLED: Sheaths were pulled at close of procedure and hemostasis achieved with manual pressure.
REEVALUATION IN RECOVERY ROOM: ECG at completion of bedrest showed possible subtle preexcitation mainly in mid-precordial leads. Adenosine was administered resulting in transient 2:1 block followed by sinus tachycardia with PR prolongation, with no change in QRS morphology throughout, arguing against residual atrioventricular pathway.
ESTIMATED BLOOD LOSS: 5 mL
FLUOROSCOPY TIME: 0 min
RADIATION DOSE: 0 mGy
DOSE AREA PRODUCT: 0 mGy x cm2 (= uGy x m2 x 10)
TOTAL CONTRAST: 0 mL
COMPLICATIONS: none
Intervals
Collection conditions: baseline.
Type of rhythm: sinus rhythm.
Ventricular cycle length: 643 ms.
P-R interval: 82 ms.
QRS duration: 117 ms.
QT interval: 393 ms.
Corrected QT interval: 490.1 ms.
A-H: 59 ms.
H-V: 0 ms.
Collection conditions: post ablation.
Type of rhythm: sinus rhythm.
Ventricular cycle length: 509 ms.
P-R interval: 120 ms.
QRS duration: 89 ms.
QT interval: 322 ms.
Corrected QT interval: 451.33 ms.
A-H: 38 ms.
H-V: 42 ms.
Atrial Pacing
Atrial site studied: left atrium via coronary sinus.
Collection conditions: baseline.
AV 1:1: 250 ms.
Drive cycle length: 450 ms.
Fast pathway AVERP: < 250 ms.
Echo beats not identified.
Accessory pathway present.
Accessory pathway drive cycle length: 450 ms.
Accessory pathway ERP: 250 ms.
Accessory pathway 1:1: 260 ms.
Adenosine response: no block and change in QRS morphology.
Atrial site studied: left atrium via coronary sinus.
Collection conditions: post ablation.
AV 1:1: 340 ms.
Drive cycle length: 450 ms.
AERP: 200 ms.
Echo beats not identified.
Accessory pathway not present.
Adenosine response: AV block.
Ventricular Pacing
Site paced: right ventricle.
Collection conditions: baseline.
VA 1:1: < 200 ms. VAERP drive cycle length: 450 ms.
VERP: 190 ms.
Atrial activation: non decremental, concentric and eccentric.
Accessory pathway present.
Accessory pathway drive cycle length: 450 ms.
Accessory pathway ERP: < 190 ms.
Accessory pathway 1:1: 200 ms.
Decremental VA conduction not noted.
Adenosine response: no block and change in atrial activation.
Both concentric and eccentric seen with adenosine
Site paced: right ventricle.
Collection conditions: post ablation.
VA conduction present.
VA 1:1: 440 ms. VAERP drive cycle length: 440 ms.
VAERP: 330 ms.
Atrial activation: decremental and concentric.
Accessory pathway not present.
Parahisian pacing: nodal response.
Adenosine response: VA block.
Arrhythmia SVT
Collection conditions: baseline.
Initiation method: substrate present without inducible arrhythmia.
Arrhythmia type: WPW.
Arrhythmia description: AVRT echo beats at baseline, isoproterenol not utilized.
APERP - baseline: 250 ms. AP 1:1 - baseline: 260 ms. Afib inducible - baseline: yes Shortest preexcited RR interval in AFib - baseline: 256 ms.
Ablation
Arrhythmia: accessory pathway.
Ablation site: left anterior.
Pathway conduction lost at 2 sec.
Comments: AP #1: After transseptal puncture, the mitral annulus was mapped in sinus rhythm for earliest activation. Pathway #1 was identified left anterior around 12:30 - 1 o'clock with early activation and QS unipolar. Ablation here resulted in abrupt change in delta wave morphology at 2.4 seconds. This lesion was completed after which local V was no longer early. We proceeded to map AP#2 and then later returned to consolidate this area..
System used: EnSite NavX (3D).
Energy type: radio frequency.
Tip size: 3.5 mm.
Irrigation tip: open irrigation tip.
Contact force used.
Number of ablations: 5.
The ablation procedure was successful.
Temperature achieved: 38 C.
Watts delivered min : 23 watts.
Watts delivered max: 30 watts.
Duration of energy delivered:188 (min:sec).
There were no complications during the procedure.
Arrhythmia: accessory pathway.
Ablation site: left anterior lateral.
Pathway conduction lost at 1 sec.
Comments: AP #2: After RF#1 resulted in change in delta morphology, the mitral annulus was remapped for earliest ventricular activation. AP#2 was identified left anterolateral around 1:30 o'clock with early activation, accessory pathway potential, and unipolar QS. The first lesion here resulted in abrupt change in delta morphology at 1.1 seconds and was completed, after which the local ventricular activation was no longer early. We proceeded to map AP#3 and later returned to consolidate this area..
System used: EnSite NavX (3D).
Energy type: radio frequency.
Tip size: 3.5 mm.
Irrigation tip: open irrigation tip.
Contact force used.
Number of ablations: 4.
The ablation procedure was successful.
Temperature achieved: 39 C.
Watts delivered min : 29 watts.
Watts delivered max: 30 watts.
Duration of energy delivered:91 (min:sec).
There were no complications during the procedure.
Arrhythmia: accessory pathway.
Ablation site: left posterior septal.
Comments: AP #3: After RF#1-#2, delta was markedly different and quite subtle but clearly still preexcited with atrial pacing. Initial mapping in the left atrium did not identify anything particularly early. The transseptal location was tagged and the catheter withdrawn to the right side. Earliest activation was identified in the proximal coronary sinus (past the middle cardiac vein) and catheter manipulation here resulted in transient mechanical suppression (local ventricular activation -14 msec to QRS). We elected to return to the left side and with a large retroflexed loop identified similarly early activation left posteroseptal where mechanical suppression again occurred (local ventricular activation -16 msec to QRS and sharp QS of similar timing) and did not recover. The catheter shadows of the two bump sites were virtually touching between the roof/front of the coronary sinus and the left atrial site (perhaps slightly behind the anatomic annulus although with favorable A:V electrogram balance) suggesting a pathway truly within the paraseptal space. Preexcitation did not recur with observation or adenosine so we proceeded to ablate fairly widely through the left posteroseptal region. We elected not to ablate with the coronary sinus although in retrospect there was a subtle change in delta wave morphology when preexcitation recovered after bump from within the coronary sinus, suggesting this could have been a branching pathway. After this we returned to reinforce the first two pathways which had only a single lesion apiece previously. There was no further antegrade nor retrograde pathway conduction through a 1 hour waiting period or with high-dose adenosine challenge..
System used: EnSite NavX (3D).
Energy type: radio frequency.
Tip size: 3.5 mm.
Irrigation tip: open irrigation tip.
Contact force used.
Number of ablations: 9.
Temperature achieved: 38 C.
Watts delivered min : 22 watts.
Watts delivered max: 30 watts.
Duration of energy delivered:458 (min:sec).
There were no complications during the procedure.
· Wolff-Parkinson-White syndrome with multiple pathways
○ Elevated-risk features for malignant arrhythmia
○ Orthodromic AV reentry tachycardia echo beats under anesthesia
○ Accessory pathway #1: left anterior
§ Successful uncomplicated radiofrequency ablation
○ Accessory pathway #2: left anterolateral
§ Successful uncomplicated radiofrequency ablation
○ Accessory pathway #3: left posteroseptal
§ Transient mechanical suppression with mapping in proximal coronary sinus
§ Lasting mechanical suppression with mapping in left atrium
§ Empiric radiofrequency ablation in left posteroseptal area
· Possible subtle preexcitation noted in recovery room
○ Physiologic first-/second-degree block with adenosine
· Normal AV node function post ablation
· Zero-radiation procedure
Procedure Comments
Procedure Comments 9 y.o. with chromosome 15q microduplication and Wolff-Parkinson-White syndrome with history of SVT in infancy, lately asymptomatic, with possible multiple delta wave morphologies on serial ECGs, presenting for EP study and ablation for prevention of sudden death.
ANESTHESIA FOR EPS/RFA. Inhalational anesthetic agents and/or propofol and endotracheal intubation were used. Please see the anesthesia record for details.
VASCULAR ACCESS. The sites were prepared in the usual sterile fashion with chlorhexidine gluconate. The areas were draped. Local anesthesia (lidocaine and/or bupivicaine) was infiltrated in the access areas before and/or during and/or after the procedure, as indicated, see log. Vascular access was achieved percutaneously with multiple sheaths for catheter placement and medication infusion; sheaths were upsized as needed during the procedure, ultimately including: 8.5 Fr RFV, 5+4 Fr LFV.
3D MAPPING ENSITE NAVX: 3D mapping was performed using the St Jude NavX Precision system for electroanatomic mapping and fluoroscopy reduction during the procedure.
FLUOROSCOPY, EPS/RFA: Digital pulsed fluoroscopy with the lowest possible exposure considering many factors using multple angulations was available to manuever the intracardiac catheters.
TRANSSEPTAL PUNCTURE: A transseptal puncture was performed to map the LA and/or LV and catheter ablation. This was performed using electroanatomic mapping and transthoracic echo due to unexpected unavailability of transesophageal echo probe for processing reasons. The fossa had been readily identified with catheter manipulation and tagged on NavX. The Baylis needle was observed on NavX to drop and engage the fossa, after which position was confirmed with subcostal imaging prior to puncture.
EP STUDY AND ABLATION: See log. Atrial fibrillation was difficult to induce but during rapid pacing and short periods of atrial fibrillation, there were at least two and probably three preexcited morphologies with rapid conduction (SPERRI <260 msec under general anesthesia) via at least two morphologies.
SHEATHS PULLED: Sheaths were pulled at close of procedure and hemostasis achieved with manual pressure.
REEVALUATION IN RECOVERY ROOM: ECG at completion of bedrest showed possible subtle preexcitation mainly in mid-precordial leads. Adenosine was administered resulting in transient 2:1 block followed by sinus tachycardia with PR prolongation, with no change in QRS morphology throughout, arguing against residual atrioventricular pathway.
ESTIMATED BLOOD LOSS: 5 mL
FLUOROSCOPY TIME: 0 min
RADIATION DOSE: 0 mGy
DOSE AREA PRODUCT: 0 mGy x cm2 (= uGy x m2 x 10)
TOTAL CONTRAST: 0 mL
COMPLICATIONS: none
Intervals
Collection conditions: baseline.
Type of rhythm: sinus rhythm.
Ventricular cycle length: 643 ms.
P-R interval: 82 ms.
QRS duration: 117 ms.
QT interval: 393 ms.
Corrected QT interval: 490.1 ms.
A-H: 59 ms.
H-V: 0 ms.
Collection conditions: post ablation.
Type of rhythm: sinus rhythm.
Ventricular cycle length: 509 ms.
P-R interval: 120 ms.
QRS duration: 89 ms.
QT interval: 322 ms.
Corrected QT interval: 451.33 ms.
A-H: 38 ms.
H-V: 42 ms.
Atrial Pacing
Atrial site studied: left atrium via coronary sinus.
Collection conditions: baseline.
AV 1:1: 250 ms.
Drive cycle length: 450 ms.
Fast pathway AVERP: < 250 ms.
Echo beats not identified.
Accessory pathway present.
Accessory pathway drive cycle length: 450 ms.
Accessory pathway ERP: 250 ms.
Accessory pathway 1:1: 260 ms.
Adenosine response: no block and change in QRS morphology.
Atrial site studied: left atrium via coronary sinus.
Collection conditions: post ablation.
AV 1:1: 340 ms.
Drive cycle length: 450 ms.
AERP: 200 ms.
Echo beats not identified.
Accessory pathway not present.
Adenosine response: AV block.
Ventricular Pacing
Site paced: right ventricle.
Collection conditions: baseline.
VA 1:1: < 200 ms. VAERP drive cycle length: 450 ms.
VERP: 190 ms.
Atrial activation: non decremental, concentric and eccentric.
Accessory pathway present.
Accessory pathway drive cycle length: 450 ms.
Accessory pathway ERP: < 190 ms.
Accessory pathway 1:1: 200 ms.
Decremental VA conduction not noted.
Adenosine response: no block and change in atrial activation.
Both concentric and eccentric seen with adenosine
Site paced: right ventricle.
Collection conditions: post ablation.
VA conduction present.
VA 1:1: 440 ms. VAERP drive cycle length: 440 ms.
VAERP: 330 ms.
Atrial activation: decremental and concentric.
Accessory pathway not present.
Parahisian pacing: nodal response.
Adenosine response: VA block.
Arrhythmia SVT
Collection conditions: baseline.
Initiation method: substrate present without inducible arrhythmia.
Arrhythmia type: WPW.
Arrhythmia description: AVRT echo beats at baseline, isoproterenol not utilized.
APERP - baseline: 250 ms. AP 1:1 - baseline: 260 ms. Afib inducible - baseline: yes Shortest preexcited RR interval in AFib - baseline: 256 ms.
Ablation
Arrhythmia: accessory pathway.
Ablation site: left anterior.
Pathway conduction lost at 2 sec.
Comments: AP #1: After transseptal puncture, the mitral annulus was mapped in sinus rhythm for earliest activation. Pathway #1 was identified left anterior around 12:30 - 1 o'clock with early activation and QS unipolar. Ablation here resulted in abrupt change in delta wave morphology at 2.4 seconds. This lesion was completed after which local V was no longer early. We proceeded to map AP#2 and then later returned to consolidate this area..
System used: EnSite NavX (3D).
Energy type: radio frequency.
Tip size: 3.5 mm.
Irrigation tip: open irrigation tip.
Contact force used.
Number of ablations: 5.
The ablation procedure was successful.
Temperature achieved: 38 C.
Watts delivered min : 23 watts.
Watts delivered max: 30 watts.
Duration of energy delivered:188 (min:sec).
There were no complications during the procedure.
Arrhythmia: accessory pathway.
Ablation site: left anterior lateral.
Pathway conduction lost at 1 sec.
Comments: AP #2: After RF#1 resulted in change in delta morphology, the mitral annulus was remapped for earliest ventricular activation. AP#2 was identified left anterolateral around 1:30 o'clock with early activation, accessory pathway potential, and unipolar QS. The first lesion here resulted in abrupt change in delta morphology at 1.1 seconds and was completed, after which the local ventricular activation was no longer early. We proceeded to map AP#3 and later returned to consolidate this area..
System used: EnSite NavX (3D).
Energy type: radio frequency.
Tip size: 3.5 mm.
Irrigation tip: open irrigation tip.
Contact force used.
Number of ablations: 4.
The ablation procedure was successful.
Temperature achieved: 39 C.
Watts delivered min : 29 watts.
Watts delivered max: 30 watts.
Duration of energy delivered:91 (min:sec).
There were no complications during the procedure.
Arrhythmia: accessory pathway.
Ablation site: left posterior septal.
Comments: AP #3: After RF#1-#2, delta was markedly different and quite subtle but clearly still preexcited with atrial pacing. Initial mapping in the left atrium did not identify anything particularly early. The transseptal location was tagged and the catheter withdrawn to the right side. Earliest activation was identified in the proximal coronary sinus (past the middle cardiac vein) and catheter manipulation here resulted in transient mechanical suppression (local ventricular activation -14 msec to QRS). We elected to return to the left side and with a large retroflexed loop identified similarly early activation left posteroseptal where mechanical suppression again occurred (local ventricular activation -16 msec to QRS and sharp QS of similar timing) and did not recover. The catheter shadows of the two bump sites were virtually touching between the roof/front of the coronary sinus and the left atrial site (perhaps slightly behind the anatomic annulus although with favorable A:V electrogram balance) suggesting a pathway truly within the paraseptal space. Preexcitation did not recur with observation or adenosine so we proceeded to ablate fairly widely through the left posteroseptal region. We elected not to ablate with the coronary sinus although in retrospect there was a subtle change in delta wave morphology when preexcitation recovered after bump from within the coronary sinus, suggesting this could have been a branching pathway. After this we returned to reinforce the first two pathways which had only a single lesion apiece previously. There was no further antegrade nor retrograde pathway conduction through a 1 hour waiting period or with high-dose adenosine challenge..
System used: EnSite NavX (3D).
Energy type: radio frequency.
Tip size: 3.5 mm.
Irrigation tip: open irrigation tip.
Contact force used.
Number of ablations: 9.
Temperature achieved: 38 C.
Watts delivered min : 22 watts.
Watts delivered max: 30 watts.
Duration of energy delivered:458 (min:sec).
There were no complications during the procedure.