(Circulation. 1995;91:1077-1085.)
© 1995 American Heart Association, Inc.
Articles |
Characteristics of the Ventricular Insertion Sites of Accessory Pathways With Anterograde Decremental Conduction Properties
From the Hôpital Cardiologique du Haut-Lévêque, Avenue de Magellan, 33604 Pessac Cédex, France, and Department of Medicine, University of Arizona College of Medicine (F.M.), Tucson, Ariz.
Correspondence to Michel Haïssaguerre, MD, Hôpital Cardiologique du Haut-Lévêque, Avenue de Magellan, 33604 Pessac Cédex, France.
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Abstract |
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Background Accessory pathways (APs) with anterograde decremental conduction properties referred to as Mahaim fibers have recently been recognized as originating from the right lateral atrium. Little information is available about their distal insertion. The purpose of this study was to determine the different kinds of APs involved and the characteristics of their distal insertion site.
Methods and Results Twenty-one patients (mean age, 28±13 years) with reciprocating tachycardia or atrial fibrillation were studied. Right-sided atrial and/or ventricular endocardial mapping during tachycardia identified different types of APs. (1) Seventeen patients had long APs originating from the right lateral atrium and coursing several centimeters to the right ventricle. In 10 patients, the AP terminated in or close to the right bundle-branch system (atriofascicular AP) and in 7, the AP terminated in the anterior right ventricle (atrioventricular AP). Patients with atriofascicular APs had narrower QRS complexes (133±10 versus 165±26 milliseconds, P=.02) and narrower initial r wave in leads V2 through V4 during maximal preexcitation than patients with atrioventricular APs. In addition, they had earlier His-bundle and right bundle-branch retrograde activation, ie, shorter V-His (16±5 versus 37±9 milliseconds, P <.01) and V–right bundle intervals (3±5 versus 25±6 milliseconds, P<.01). In 6 patients, minimal preexcitation not readily apparent was present in sinus rhythm despite the appearance of a narrow QRS complex. A wide distal insertion site of 0.5 to 2 cm in diameter consistent with arborization of the AP was found in 10 patients. The distal application of radiofrequency current produced a change in the preexcitation pattern in 4 patients and ablated the AP in 2 patients. In the other patients, radiofrequency current was applied more proximally and successfully ablated the AP bundle (n=9) or AP proximal insertion (n=6). No recurrence was observed during a follow-up period of 12±10 months. (2) Four patients had short paratricuspid atrioventricular APs; in one, the decremental conduction property was acquired as demonstrated by two electrophysiological studies performed 7 years apart. Radiofrequency ablation was successfully accomplished in all 4 patients at the tricuspid annulus.
Conclusions Different types of APs account for tachycardias previously called Mahaim fibers. Long and short atrioventricular APs are observed in 81% and 19%, respectively. Long APs often have a distal arborization and may have either a fascicular or ventricular insertion. Radiofrequency current is more efficient when applied to the AP bundle or AP proximal insertion rather than to the distal insertion in patients with long APs.
Key Words: catheter ablation • accessory nerve • atrioventricular node • bundle of His • tachycardia
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Introduction |
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Recent studies have shown that most antidromic tachycardias involving an accessory pathway (AP) referred to as nodoventricular Mahaim fibers1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 originate from the right lateral atrium.19 20 21 22 23 24 25 Because these APs are thought to be connected to the right bundle branch, they are widely called atriofascicular tracts.25 26 27 28 29 30 31 32 33 They are either implicated or serve a bystander role in paroxysmal reciprocating tachycardias with a left bundle-branch pattern.
These pathways have the uncommon property of slow and decremental conduction. In patients with drug-refractory tachycardias, radiofrequency catheter ablation of the anomalous pathway has now become the curative treatment of choice.26 27 28 29 30 31 32 33 34 Meticulous mapping of the tricuspid annulus made it possible to record consistent AP proximal activation potential that was used to successfully ablate the pathway.28 29 30 31 32 33 34
In the present report, we describe a series of patients whose distal insertion of decremental conducting APs was explored, allowing the identification of different kinds of APs.
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Methods |
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Patient Characteristics
This study population consists of 21 patients, 11 male and 10 female, with a mean age of 28±13 years (range, 7 to 52 years). Clinical characteristics are summarized in Table 1
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Baseline Electrophysiological Study
Electrophysiological
study was performed under general
anesthesia in patient 11; the others received diazepam 10 to 20 mg IV
before the procedure. Antiarrhythmic drugs were discontinued for at
least five half-lives in all patients except for 3 patients who were
taking amiodarone. Two, three, or four 6F or 7F steerable or
nonsteerable multipolar electrode catheters (Bard Electrophysiology or
Polaris) were placed simultaneously or at different times at the
His-bundle and proximal right bundle-branch region, the coronary sinus,
the right atrium, and the right ventricle. The catheters used to apply
radiofrequency energy were steerable and had a tip electrode 4 mm long
(Polaris). Bipolar electrograms were recorded at a paper speed of 100
mm/s with a polygraph (model VR 12, Electronics-for-Medicine or model
Midas, PPG Biomedical) at a filter setting of 30 to 500 Hz. All
recordings used bipolar electrodes separated by 2 mm at a gain of 5 to
10 cm/mV. "Unfiltered" unipolar electrograms were obtained from
the surface ECG channels of the recorder. Stimuli were twice diastolic
threshold and 2 milliseconds in duration.
Decremental AP conduction was
defined as a rate-dependent prolongation
of conduction time 
30 milliseconds through the AP as measured in the
electrograms closest to the AP insertion. In patient 19, who had two
electrophysiological studies, in 1986 and 1993, AP conduction was not
decremental during the first study, whereas it fulfilled the inclusion
criteria of decremental conduction during the second study. In all
patients, participation of the decremental connection as a component of
the tachycardia circuit was defined according to criteria previously
described.6 AP conduction properties and their refractory
periods were determined after ablation of other APs in 5 patients. In
addition, the sequence of His-Purkinje activation using the AP was
assessed. The activation timing of right bundle branch was measured 1
to 1.5 cm distal to the point at which the His-bundle potential was
recorded. Adenosine triphosphate (20 to 50 mg) (adenosine triphosphate
is not the same preparation as adenosine that is commercially available
in the United States.) was administered in 15 patients to determine the
effect on the AP.
The proximal atrial versus nodal insertion of the AP was determined by delivering right atrial extrastimuli during tachycardia when the atrioventricular (AV) node was refractory.25 An advance in the timing of the next ventricular complex indicated an atrial insertion of the AP. In most patients, the proximal atrial insertion was localized with the recording of the AP potential.28 29 35 The distal insertion of the AP was defined by recording both the earliest bipolar ventricular activation relative to the preexcitation onset and a steep QS pattern of the unipolar waveform. At this site, the presence of a spike immediately preceding the ventricular electrogram26 suggested the recording of the distal AP–ventricle interface. The distal AP insertion was considered to be fascicular if a right bundle-branch potential was also present before nonpreexcited QRS complexes. It was considered to be ventricular if no specific potential was locally present before nonpreexcited QRS complexes. The location of the different sites was established with the anterior and 45° right anterior oblique views for the distal insertion and the 60° left anterior oblique radiological view for the proximal insertion.
Catheter Ablation
In all patients, the AP was ablated with
radiofrequency current.
The generator was the HAT 100 or the HAT 200 (Osypka GmbH), which
delivered a 500-kHz sine wave between the distal electrode of the
ablation catheter and a 110-cm2 cutaneous patch electrode
placed over the left scapula. A power setting of 30 to 50 W was used.
Delivered current was continuously observed on the HAT 200 during
energy delivery, but these data were not stored. Radiofrequency energy
was delivered for 60 to 90 seconds at each successful ablation site or
for only 30 seconds when there was no apparent change in the
electrogram. Energy delivery was stopped sooner if there was
inadvertent catheter movement or a marked impedance rise. The ablation
procedure was considered successful if, at the end of impulse delivery
and 20 minutes later, AP conduction was abolished.
Heparin was only administered immediately after the procedure was completed in a dose of 0.5 mg/kg body wt IV followed by a subcutaneous low-molecular-weight preparation (enoxaparine), 20 to 40 mg once a day for 5 days. A two-dimensional Doppler echocardiogram was obtained 2 to 4 days after the ablation. A follow-up electrophysiological study (either endocavitary or transesophageal) was performed in 9 patients 1 to 8 weeks after the ablation. In the other patients, the absence of clinical tachycardias and preexcitation on ECG was considered indicative of successful ablation.
Statistical Analysis
Values are given as mean±SD. The
significance of differences
between groups of clinical and electrophysiological parameters was
assessed by Student's t test or Fisher's exact test.
P<.05 was considered a significant difference.
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Results |
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Different types of decremental APs could be clearly distinguished (Fig 1
). The clinical and electrophysiological data are
presented in Tables 1
and 2. Additional relevant
information is reported below.
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Long AV Bundle (17 Patients)
These APs were defined by a
proximal atrial insertion and a
ventricular insertion more than 2 cm from the tricuspid annulus. In 11
patients, the proximal AP insertion was localized at the tricuspid
annulus in a circumscribed area as shown in Fig 1. In 8 of
these
patients, a slow potential similar to that described in the AV nodal
region36 was consistently recorded between the atrial and
AP potentials (Fig 2) at the atrial aspect of the
tricuspid annulus. Although it appeared to prolong at higher rates,
this could not be ascertained with certainty because of the instability
of the mapping catheter. During sinus rhythm, a bolus of adenosine
triphosphate was given to 13 patients, resulting in preexcitation with
a long P-delta interval in 11 patients (85%).
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Distal Insertion
The distal insertion was observed several centimeters from the
tricuspid annulus, on the right anterior wall, up to the septum (Figs
1 and 3). In 10 patients, similar QS patterns of
the
unipolar electrograms and similar bipolar electrograms were observed at
several sites in an area 0.5 to 2 cm in diameter, suggesting distal
arborization of the AP (Fig 4). In 7 patients, the AP
distal insertion appeared localized. The maximal peaks of ventricular
electrograms occurred 0 to 15 milliseconds before the onset of
preexcited QRS complexes and were immediately preceded by a sharp
potential of 0.1 to 0.45 mV. In 7 patients (41%), this potential was
absent before the local electrogram during nonpreexcited QRS complexes
(Fig 5), thus excluding a potential from the right
bundle-branch system (atrioventricular AP). In 10 patients (59%), a
sharp potential was present immediately before preexcited as well
as nonpreexcited complexes (atriofascicular AP). In 3 of these
patients, some parts of the distal insertion showed right bundle-branch
potentials, whereas others did not. The definition of nonpreexcited QRS
complexes could not be definitely based on the presence of a narrow QRS
complex and normal HV interval. Indeed, in 6 patients, minimal
preexcitation sometimes intermittently was present in sinus rhythm
and could be suspected in 4 patients by the absence or decrease of
septal Q wave in leads V5 and V6. Preexcitation
was proved by a subtle change in both the morphology of the narrow QRS
complex and HV interval during pacing of the interatrial septum and a
similar change in the ECG pattern in sinus rhythm after AP ablation.
Therefore, a distal AP potential may be confused with a right
bundle-branch potential if either this pacing maneuver is not done or
an exclusively normal QRS complex is not selected.
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Comparison of Characteristics in AV and Atriofascicular APs
Different parameters differentiated patients with atriofascicular
and AV APs (Table 3). Ebstein's anomaly and the
presence of another AP were more frequent in association with AV APs,
but the difference was not significant. Patients with atriofascicular
APs had narrower QRS complexes (133±10 versus 165±26
milliseconds,
P=.02) during maximal preexcitation and earlier His-bundle
and right bundle-branch retrograde activation, ie, shorter V-His (16±5
versus 37±9 milliseconds, P<.01) and V–right bundle
intervals (3±5 versus 25±6 milliseconds, P<.01) than
patients with AV APs. In addition, they always had a narrow r wave in
leads V2 to V4, whereas a broad r wave
(>40 milliseconds) was present in one or more of these leads in 5
patients with AV APs (Fig 6). Finally, in patients in
whom a proximal AP potential was recorded at the annulus, the AP
potential–delta wave interval was longer in atriofascicular APs
(66±16 versus 34±8 milliseconds, P<.01) with extreme
values of 45 to 90 and 30 to 45 milliseconds, respectively (Fig
2).
There was no difference in the incidence of slow potentials at the
tricuspid annulus.
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Midpart of the AP Bundle
When
the catheter was moved 5 to 15 mm proximally by turning the
femoral catheter counterclockwise, it was possible to record a
potential originating from the AP bundle. The potential was well
separated from the ventricular potential, which showed an rS pattern in
unipolar recordings. The potential had an amplitude of 0.05 to 0.4 mV
with a single spike in 13 patients, a double or fractionated potential
in 2 patients, and a widened (30 milliseconds) potential in 2
patients (Fig 7). It occurred 20 to 50 milliseconds
before the onset of preexcitation and was also present before the
nonpreexcited QRS complexes but with a longer interval to the onset of
ventricular activation. In some patients, the recording of this
potential was extremely difficult because of catheter instability; it
could easily be missed unless specifically sought. A transient
mechanical block of the AP was observed in 8 patients during excursion
of the catheter at these sites.
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Radiofrequency Catheter
Ablation
In the first 11 patients, radiofrequency energy was applied
to the
distal AP insertion with a median of 5 and a mean of 8±5 (2 to 18)
applications. Ablation was successful at this site in only 2 patients.
It was unsuccessful in the other 9 patients but produced a change in
the preexcitation pattern either progressively in 3 patients (Fig
4) or
suddenly in 1 patient (Fig 8). In most cases, the distal
AP potential at the target site had disappeared after the energy
application (Fig 8). Right bundle-branch block occurred in 1
patient.
In no case was the tachycardia facilitated by these unsuccessful
attempts. Ablation was successfully accomplished in 9 patients by
delivering 1 to 4 applications (median, 2) to the site where a stable
AP bundle potential was recorded. After ablation, the targeted AP
potential disappeared, but in 6 patients the persistence of potentials
from a more proximal level was recorded (Fig 9). In 6
patients, a stable AP bundle potential could not be obtained, and
radiofrequency energy was successfully applied to the atrial proximal
AP insertion with 1 to 4 applications (median, 1). Follow-up study
performed in 8 patients confirmed elimination of the AP. One patient
(patient 8) had an intermittent fasciculoventricular AP6
without inducible tachycardia. Tachycardias did not recur in any
patient over a follow-up period of 12±10 (2 to 36) months.
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Short AV APs (4 Patients)
These APs were thus defined because
both atrial and ventricular
insertions were immediately contiguous to the tricuspid annulus. During
maximal preexcitation, the His potential was observed within the
ventricular electrogram more than 25 milliseconds after its onset.
During sinus rhythm, a bolus of adenosine triphosphate administered to
2 patients produced no prolongation of the P–delta wave interval. The
earliest ventricular electrogram during preexcitation was found at the
tricuspid annulus with a mean local AV time of 46±22 milliseconds.
Radiofrequency delivery of one to four applications (median, two) at
the right posteroseptal or lateral regions eliminated both
preexcitation and inducibility of reciprocating tachycardias in all
patients. Neither tachycardia nor preexcitation recurred in any
patient. Follow-up study confirmed AP elimination in 1 patient.
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Discussion |
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This report describes patients presenting with antidromic reentrant tachycardia or atrial fibrillation exhibiting preexcited QRS complexes having a left bundle-branch block pattern. It shows that APs with anterograde decremental conduction properties include different types of fibers, both confirming and expanding previous observations.24 25 26 27 28 29
Different Electrophysiological Characteristics of the Distal
Insertion
The usual electrophysiological definition of Mahaim fibers
is that
they have a basic long AV conduction time and this interval becomes
longer by atrial stimulation through the AP or its interfaces,
resulting in much longer conduction times than are usually observed
with the classic AP. The electrophysiological properties must be
assessed at or close to the AP insertion site to exclude decremental
conduction in the tissue intervening between pacing and recording
sites, particularly if Ebstein's anomaly is present. In contrast
to previous reports, preexcitation is found in 50% of patients during
sinus rhythm, often in a subtle form. This can be suspected if a septal
Q wave is not present in leads V5 or V6.
The conduction properties were unidirectional in the anterograde
direction in our patients, as in the studies of other authors. However,
we reported previously 1 patient who, despite no apparent
ventriculoatrial conduction, had retrograde conduction through the
distal part of a decremental AV AP that blocked at its proximal atrial
insertion (AP potential not followed by atrial
activity).35
Although APs have a common electrophysiological definition, they involve different electrophysiological characteristics. As previously shown, these APs have a proximal atrial insertion, and most are long AV bundles measuring several centimeters. In the present study, the distal insertion of these pathways is more clearly characterized. First, they appear to have a broad distal insertion suggested by the fact that spike potentials fusing with the earliest bipolar ventricular potentials can be recorded over a relatively large area. The use of unipolar electrograms is useful because the QS morphology confirms the earliest onset of the ventricular activation through the AP. Furthermore, an initial steep deflection indicates that the electrode records the underlying local activity rather than that from some distance. Ablation with one or two DC shocks could be successfully accomplished in this distal location26 but required multiple applications of radiofrequency energy to be successful. In 4 patients, applications of radiofrequency energy distally produced a progressive or sudden change in the ventricular preexcitation pattern, strongly supporting distal arborization. The disappearance of spike potential after radiofrequency application suggests that the change was due to modification of the AP itself rather than the ventricular muscle. However, particularly in atriofascicular APs, we cannot exclude that an interconnection with the local His-Purkinje network leads to a simultaneous activation of a wide area, giving the appearance of AP arborization. No proarrhythmic effect was observed during these unsuccessful attempts, as hypothesized in some previous studies.28 33 In the last patients, radiofrequency energy was applied to the more proximal parts of the AP either at the long AP bundle or at the AP proximal insertion. Fewer energy applications were required because these anatomic structures are circumscribed.
Second, although the distal insertion enters the anterior wall of the right ventricle, in 41% of the patients it appears not to be directly connected to the right bundle-branch system, as evidenced by the absence of His-Purkinje potentials ahead of nonpreexcited QRS complexes. The ventricular muscle insertion is strongly supported by a mean delay of 22 milliseconds in the retrograde activation of right bundle branch (and His bundle), a figure strikingly similar to the results of an experimental study comparing the effects of ventricular versus fascicular stimulation.37 This observation suggests that, in contrast to these pathways being called atriofascicular, some may be atrioventricular. In other patients, the AP distal insertion could not be separated from the right bundle-branch system, indicating an atriofascicular AP. Patients with long AV APs may be recognized when wide preexcited QRS complexes with broad initial r waves are present on the ECG. Interestingly, they also have an interval from the proximal AP potential to the preexcitation onset that is clearly shorter than in patients with atriofascicular APs. This finding suggests a shorter course of the AP bundle. In contrast to our observations, McClelland et al28 did not find any patients with a long AV AP. This may be due to differences in the two populations. In their study, there were fewer patients with Ebstein's anomaly and other associated APs.
Short AV APs inserting at the base of the right ventricle can be readily differentiated from long APs by mapping the distal insertion that is close to the tricuspid annulus. Furthermore, in the absence of retrograde right bundle-branch block, the ventriculohissian time during preexcitation is usually longer in those using shorter APs because of the greater amount of myocardial (nonspecialized) tissue intervening during retrograde conduction. In 2 patients with short APs, adenosine triphosphate produced no effect, whereas it prolonged the P-delta interval in 85% of long APs whether they were atriofascicular or atrioventricular. The mechanism may be due to the involvement of nodal tissue in long APs, a hypothesis also supported by the presence of slow potentials at their proximal insertion site where the effect of adenosine occurs.28 However, whether the effects of adenosine triphosphate can help to distinguish the different APs needs to be confirmed with more observations.
Anatomic Substrates
There has been no report correlating the
anatomy and
electrophysiology of long AV pathways with decremental conduction
properties. A study by Guiraudon et al38 showed that such
a pathway included nodal cells at its proximal insertion. Becker et
al16 17 pointed out the relation of this observation
to
the original anatomic description by Kent of an "accessory
pathway" in which there was an accessory node located on the lateral
tricuspid annulus. They reported in association with Ebstein's anomaly
a nodelike structure associated with a bundle of specialized fibers
measuring 1 cm and coursing through the right ventricle, mimicking a
second AV conducting system. Such connections are remnants of
specialized embryonic ring tissue.
Likewise, anatomic data are lacking
concerning short decrementally
conducting AV pathways. However, our observation of a classical AP
acquiring such properties (patient 19) suggests that some may be due to
alteration of conduction properties of APs. This has some similarity
with our two other patients associated with Ebstein's anomaly in which
the tricuspid annulus and periannular tissue have structural
abnormalities. In a review of the literature, we noted an observation
in a study of a squirrel monkey reported by Boineau et
al.39 The animal had a right lateral preexcitation that
showed decremental properties as seen in their Fig 2A.
Histology of
this pathway showed no proximal node but an insulated bundle with a
tortuous 1-cm course to the ventricle. This finding is strikingly
similar to that reported by Critelli et al40 in a human
case of a permanent form of reciprocating tachycardia involving another
type of AP with decremental retrograde conduction properties.
Therefore, it is clear that a wide spectrum of anatomic substrates can
be responsible for an AP with decremental conduction properties,
including a tortuous long AP, structural or histological abnormality of
the AP, or inclusion of nodal tissue.
Received August 1, 1994; accepted September 23, 1994.
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