Challenge of the Week
May 7th Question: Amit Noheria
A 14-year-old girl with Wolff-Parkinson-White syndrome and recurrent paroxysmal palpitations due to atrioventricular reentry tachycardia had undergone two prior failed left lateral accessory pathway ablations at another institution and is now referred to you. Her electrocardiogram is shown in Figure 1. She is brought to the electrophysiology laboratory and orthodromic atrioventricular reentry tachycardia is inducible. Figure 2 shows the fluoroscopic catheter locations and correlating intracardiac electrograms. Ventriculoatrial conduction time is constant with ventricular pacing at different cycle lengths. Figure 3 shows a paraHisian pacing maneuver. What can you say about the accessory pathway?
Figure 1: Twelve-lead electrocardiogram.
Figure 2A: Fluroscopy. Right anterior oblique and left anterior oblique fluoroscopic views to show catheter positions.
Figure 2B. Intracardiac electrograms. Correlating intracardiac electrograms. P1 ART is the arterial blood pressure tracing; I, II, aVF and V1 represent surface electrocardiogram leads; RVa, right ventricular apex; HRA, high right atrium; HIS 4 to HIS 1, His bundle electrograms proximal to distal; ABL p, ablation catheter proximal; ABL d, ablation catheter distal; CS 19,20 to CS 1,2, coronary sinus catheter proximal to distal.
Figure 3. ParaHisian pacing maneuver.
A. There is evidence for more than one accessory pathway.
B. There is evidence for accessory pathway slant from atrial insertion at CS 7,8 and ventricular insertion at CS 1,2.
C. The ventriculoatrial conduction is via the atrioventricular node.
D. Ablation should be performed at the location of the ablation catheter (ABL d) in Figure 2.
E. Left atrial appendage should be mapped.
April 30th Answer: B. Atrial septal defect
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|April 30th Question: Amit Noheria|
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|April 2nd Question: Pasquale Santangeli (March 26th Answer)|
|March 26th Question: Pasquale Santangeli (March 19th Answer)|
|March 19th Question: Amit Noheria (March 12th Answer)|
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|March 5th Question: Amit Noheria (February 26th Answer)|
|February 26th Question: Pasquale Santangeli (February 19th Answer)|
|February 19th Question: Amit Noheria (February 12th Answer)|
|February 12th Question: Amit Noheria, Phillip S. Cuculich (February 5th Answer)|
|February 5th Question: Amit Noheria (January 29th Answer)|
|January 29nd Question: Amit Noheria (January 22nd Answer)|
|January 22nd Question: Amit Noheria (January 15th Answer)|
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|January 8th Question: Amit Noheria|