Korean Circ J.  2016 Jul;46(4):574-579. 10.4070/kcj.2016.46.4.574.

Spontaneous Transition of Double Tachycardias with Atrial Fusion in a Patient with Wolff-Parkinson-White Syndrome

• Kim D
• Lee MY

• KMID: 2344435
• DOI: http://doi.org/10.4070/kcj.2016.46.4.574

Abstract

Among patients with Wolff-Parkinson-White syndrome, atrioventricular reciprocating tachycardia (AVRT) and atrioventricular nodal reentrant tachycardia (AVNRT) can coexist in a single patient. Direct transition of both tachycardias is rare; however, it can occur after premature atrial or ventricular activity if the cycle lengths of the two tachycardias are similar. Furthermore, persistent atrial activation by an accessory pathway (AP) located outside of the AV node during ongoing AVNRT is also rare. This article describes a case of uncommon atrial activation by an AP during AVNRT and gradual transition of the two supraventricular tachycardias without any preceding atrial or ventricular activity in a patient with preexcitation syndrome.

Keyword

Tachycardia, atrioventricular nodal reentry; Tachycardia, reciprocating; Tachycardia, paroxysmal; Tachycardia, supraventricular; Wolff-Parkinson-White syndrome

MeSH Terms

Atrioventricular Node
Humans
Pre-Excitation Syndromes
Tachycardia*
Tachycardia, Atrioventricular Nodal Reentry
Tachycardia, Paroxysmal
Tachycardia, Reciprocating
Tachycardia, Supraventricular
Wolff-Parkinson-White Syndrome*

Figure

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  Fig. 1 A 12-lead electrocardiogram. Intermittent preexcitation was noted in the late recovery phase during the treadmill test. Delta wave polarity suggested an accessory pathway in the left free wall.

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  Fig. 2 Induced tachycardia (upper) and schematic drawing of atrial activation (below). Fusion of the sequence of retrograde atrial activation with slight lengthening of the tachycardia CLs, followed by transition to AVRT using the left free wall accessory pathway. The VA interval of 70 msec measured in the distal CS recording was constant. CL: cycle length, AVRT: atrioventricular reciprocating tachycardia, VA: ventriculoatrial, CS: coronary sinus, RA-H: right atrium high, RA-L: right atrium low, HISp: His-bundle electrogram proximal, HISd: His-bundle electrogram distal, CSp: coronary sinus proximal, CSd: coronary sinus distal, RVA: right ventricle apex, LA: left atrium, AP: accessory pathway.

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  Fig. 3 His-synchronous ventricular extrastimulation. Although the short VA intervals in the proximal CS region suggested AVNRT, atrial activation was advanced (418 msec to 414 msec) with single premature ventricular pacing at a time of His-bundle refractoriness (arrowhead). VA: ventriculoatrial, CS: coronary sinus, AVNRT: atrioventricular nodal reentrant tachycardia.

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  Fig. 4 Fluoroscopic imaging of the ablation site. Left anterior oblique fluoroscopic views of the successful radiofrequency catheter ablation site at the anterolateral aspect of the mitral annulus via a transseptal approach (A) and at the triangle of Koch for slow pathway modulation (B). Abl: ablation catheter, CS: coronary sinus.

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  Fig. 5 Induction of tachycardia by single atrial extra-stimulation (A1A2 600/360 msec) after the AP ablation. The retrograde atrial activation sequence was concentric, suggesting typical slow-fast AVNRT. Note splitting of the VA interval in the distal CS recording in comparison with that in Fig. 2. RA-H: right atrium high, RA-L: right atrium low, HISp: His-bundle electrogram proximal, HISd: His-bundle electrogram distal, CSp: coronary sinus proximal, CSd: coronary sinus distal, RVA: right ventricle apex, LA: left atrium, AP: accessory pathway, AVNRT: atrioventricular nodal reentrant tachycardia, VA: ventriculoatrial, CS: coronary sinus.

Reference

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