His Bundle Recordings in Patients with Reciprocating Tachycardias and Wolff-Parkinson-White Syndrome
TL;DR: The mechanisms of reciprocating tachycardias were studied in three patients with WPW syndrome using the catheter technic of His bundle recordings, finding that short-lived paroxysms of atrial fibrillation in cases 1 and 2 were most probably related to atrial vulnerability.
Abstract: The mechanisms of reciprocating tachycardias were studied in three patients with WPW syndrome using the catheter technic of His bundle recordings. In the first case it could not be determined with certainty whether the tachycardias involved two anatomically independent fascicles or a single longitudinally dissociated pathway. They were terminated by carotid sinus pressure, which caused A-V nodal block, or by properly timed atrial stimuli, which interrupted the circuit. Short-lived paroxysms of atrial fibrillation in cases 1 and 2 were most probably related to atrial vulnerability. In case 3 there were three types of QRS complexes in lead II representing (a) exclusive His bundle conduction, (b) simultaneous His and Kent bundle conduction, and (c) coexisting His and infra-nodal preferential (Mahaim fiber[?]) conduction. This patient also had three types of reciprocating tachycardias-two of ventricular, and one of atrial origin. The reciprocating circuit probably involved the three pathways.
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TL;DR: The results favor reentry as the causal mechanism for the tachycardias in patients who suffered from recurrent attacks of ventricular tachycardsia.
Abstract: The initiation and termination of tachycardias were studied in five patients who suffered from recurrent attacks of ventricular tachycardia. In four, coronary artery disease with old myocardial infarction was present. A ventricular tachycardia could be initiated in all patients by a single right ventricular premature beat given during regular driving of the right ventricle. The tachycardia could be terminated by a single right ventricular premature beat, or two right ventricular premature beats given in close succession. In four of our patients an early right ventricular premature beat was followed by the next QRS complex of the tachycardia after an interval shorter than compensatory. Our results favor reentry as the causal mechanism for the tachycardias in our patients. Possible pathways for circus reentry leading to ventricular tachycardia can theoretically be composed of (1) the bundle branches, (2) Purkinje fibers with or without adjacent ventricular myocardium, (3) infarcted or fibrotic ventricular tissue, and (4) combinations of (1), (2), and (3).
489 citations
TL;DR: It is felt that in selected patients, surgical correction of the WPW syndrome is entirely feasible, and can be accomplished in the majority of patients in whom free wall A-V connections are present.
Abstract: Physiological studies of the type we have described, when performed in patients with the WPW syndrome, can yield diagnostic information regarding the mechanism of arrhythmia, demonstrate functional properties of therapeutic import, facilitate therapeutic decision-making about drug regimens and presumptively localize the site of pre-excitation as a basis for possible surgical intervention. Based on our experience, we feel that in selected patients, surgical correction of the WPW syndrome is entirely feasible, and can be accomplished in the majority of patients in whom free wall A-V connections are present. The continuing challenge of identification and correction of septal accessory pathways directs our present work with the WPW syndrome.
383 citations
TL;DR: Electrophysiologic evaluation in five patients who exhibited manifestations of the pre-excitation syndrome and/or supraventricular tachycardia provided functional evidence that the properties of the accessory fibers may be quite variable, and anomalies in conduction over accessory pathways were demonstrated.
Abstract: Electrophysiologic evaluation in five patients who exhibited manifestations of the pre-excitation syndrome and/or supraventricular tachycardia provided functional evidence that the properties of the accessory fibers may be quite variable. The unusual responses to electrical stimulation in these patients included: 1) failure to depolarize the His bundle from the site of ventricular pre-excitation; 2) supraventricular tachycardia with two types of re-entry; 3) anterograde block in the accessory pathway with intact retrograde conduction; and 4) retrograde delay or block in the accessory pathway and atrioventricular (A-V) node with intact anterograde conduction. Understanding these variations may provide important therapeutic implications regarding drug and surgical management. In addition to these anomalies in conduction over accessory pathways we demonstrated in these patients the occurrence of retrograde functional right bundle branch block and retrograde "gap" phenomenon, and ventricular reciprocation wit...
235 citations
TL;DR: It is suggested that the occurrence of this electrophysiological phenomenon may be more common than is generally appreciated, and optimal medical treatment should be directed toward controlling both RT and AF in this group of Wolff-Parkinson- White patients.
Abstract: In a group of 36 consecutive patients with the Wolff- Parkinson-White (WPW) syndrome undergoing electrophysiological studies because of paroxysms of reciprocating tachycardia (RT) and/or atrial flutter-fibrillation (AF), 7 patients (19%) had repeated episodes of spontaneous alternation between RT and AF. Electrophysiological studies demonstrated left-sided anomalous pathways (AP) in all 7 patients. Atrial vulnerability, as evidenced by the occurrence of repetitive atrial responses or a paroxysm of AF following a single atrial premature stimulus, was also noted in all. Invariably, spontaneous conversion of RT to AF (7 patients) was triggered by an atrial premature depolarization which resulted in atrial asynchrony during the atrial vulnerable phase. In contrast, spontaneous conversion of AF to RT (3 of the 7 patients) required the presence or the development of antegrade unidirectional block in the AP prior to the cessation of AF. The demonstration of atrial vulnerability in association with the phenomenon of spontaneous alternation between RT and AF provides further information pertaining to the understanding of the mechanisms of tachyarrhythmias in the WPW syndrome. It is suggested that the occurrence of this electrophysiological phenomenon may be more common than is generally appreciated, and optimal medical treatment should be directed toward controlling both RT and AF in this group of Wolff-Parkinson- White patients.
138 citations
TL;DR: Electrophysiological studies in five patients with documented paroxysmal supraventricular tachycardia suggested sinus or atrial re-entrance (SR or AR), which appear to be mechanisms of spontaneous PSVT in man.
Abstract: Electrophysiological studies in five patients with documented (4) or suspected (1) paroxysmal supraventricular tachycardia (PSVT), suggested sinus or atrial reentrance (SR or AR). Two of the patients had preexcitation, three had evidence of atrial enlargement, and all had organic heart disease. The following observations supported a diagnosis of SR and AR; 1) induction of sustained PSVT with atrial extrastimulus technique allowing definition of an echo zone; 2) induction of sustained PSVT during constant rapid atrial pacing at a rate less than that producing A-V nodal Wenckebach periods, or producing normalization of QRS complex in patients with pre-excitation: 3) P waves preceding each QRS during PSVT with an A-H interval appropriate for the rate of the PSVT; 4) antegrade P wave morphology during PSVT, a normal high to low sequence of right atrial activation (SR), or P wave morphology and atrial activation sequence different from sinus (AR); 5) lack of correlation of PSVT induction with critical A-H interval. The rates of induced sustained PSVT ranged from 114 to 143 beats/min, and were similar to those observed during spontaneous episodes of PSVT in the four patients. PSVT could be terminated with critically timed extra-stimuli or carotid massage. In conclusion, SR and AR appear to be mechanisms of spontaneous PSVT in man. Rates of SR and AR PSVT tend to be relatively slow.
134 citations
References
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TL;DR: The use of this recording technique in man will facilitate diagnostic interpretation of the electrocardiogram and can be used in various investigations of atrioventricular and intraventricular conduction in man.
Abstract: A technique for the routine recording of His bundle (H) activity in man using a bipolar or multipolar catheter is described. The recording catheter is inserted percutaneously, via the Seldinger method, into the right femoral vein and advanced fluoroscopically into the right atrium. Placement of the pre-formed curve at the catheter tip across the tricuspid valve in nine patients resulted in stable recordings of His bundle activity in successive cardiac cycles. Right atrial pacing resulted in progressive lengthening of the P-H interval with increasing frequency but the H to S-wave interval remained constant at all rates. Similar lengthening of the P-H interval was produced during atrial pacing when pressure was applied to the carotid sinus. The use of this recording technique in man will facilitate diagnostic interpretation of the electrocardiogram and can be used in various investigations of atrioventricular and intraventricular conduction in man.
1,112 citations
TL;DR: A study of the transmission of early premature contractions between atria and ventricles and in the retrograde direction in the dog heart suggests the existence of two parallel A-V conduction pathways communicating with each other over one or more branches.
Abstract: A study of the transmission of early premature contractions between atria and ventricles and in the retrograde direction in the dog heart suggests the existence of two parallel A-V conduction pathways communicating with each other over one or more branches. The evidence is based on the excessive delay of very early premature responses in traversing the node, suggesting that a slowly conducting pathway recovers earlier than the normal "fast" pathway; on the echoing back to the chamber of origin of early premature responses; and on ventricular electrograms of "abnormal" configuration obtained during early premature responses. These observations and the hypothesis to which they lead provide a natural explanation for reciprocal rhythm and nodal paroxysmal tachycardia.
480 citations
TL;DR: In four patients with WPW syndrome atrial and ventricular premature beats were induced and the changes in form of the ventricular and atrial complexes were studied, results suggest that a circus movement involving the atria, the normal atrioventricular conduction system and the Kent bundle is present.
Abstract: In four patients with WPW syndrome atrial and ventricular premature beats were induced and the changes in form of the ventricular and atrial complexes were studied. Results indicate that, depending upon the timing of the premature atrial beat and the state of refractoriness of the His and Kent bundles, excitation of the ventricles occurs predominantly through the atrioventricular nodal system, predominantly through the Kent bundle or exclusively through one or both conduction systems. With short delays conduction through the Kent bundle may be blocked and only normal excitation of the ventricles occurs. In one patient with a history of attacks of tachycardia these normal QRS complexes were followed by retrograde activation of the atria by the Kent bundle, and attacks of supraventricular tachycardia of shorter or larger duration occurred. They stopped spontaneously, sometimes by delay or block, either of retrograde Kent conduction or of antegrade A-V nodal conduction, making it possible for the sinus node to capture the ventricles. They also could be terminated by induced atrial premature beats.
456 citations
Journal Article•
225 citations
TL;DR: Two patients with WPW syndrome underwent surgery to ablate accessory conduction pathways and the areas of early right ventricular depolarization failed in both cases to normalize the electrocardiogram.
Abstract: Two patients with WPW syndrome underwent surgery to ablate accessory conduction pathways. Endocardial and epicardial mapping in both patients had indicated an area of early right ventricular depolarization. Surgical transection of the areas of early depolarization failed in both cases to normalize the electrocardiogram. In the first patient, additional resection in the area of the A-V node failed to produce heart block and the ECG remained abnormal. However, the paroxysmal tachycardia ceased, and she has remained asymptomatic and active 12 months after surgery. In the second patient, as the A-V node was about to be sectioned, pressure and procaine near the A-V node caused the ECG to normalize transiently and after resection permanently. Microscopic study of this tissue showed "P cells." Postoperatively the patient demonstrated normal A-V nodal function. He was discharged with a normal ECG but expired soon after discharge. Postmortem examination of the heart demonstrated the A-V node and bundle of His plus the location of the resection adjacent to the bundle of His. These two cases illustrate disparities between electrophysiologic mapping and actual site of the accessory conduction pathway. In one of the cases an accessory bundle was demonstrated histologically.
171 citations