Wide QRS tachycardia in a patient with pre excitation; what are the pathways involved? Pacing manoeuvres to characterize a unique pathway
A 30year old patient presented to us with recurrent episodes of palpitation and documented tachycardia. In all his presentations a wide QRS tachycardia was recorded. The baseline ECG showed pre excitation. The 12 lead ECG of the tachycardia and the baseline ECG is shown in Fig. 1A. During EP study t...
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| Format: | Article |
| Language: | English |
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Elsevier
2017-03-01
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| Series: | Indian Pacing and Electrophysiology Journal |
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| Online Access: | http://www.sciencedirect.com/science/article/pii/S0972629216314073 |
| _version_ | 1828725061429755904 |
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| author | Krishna Kumar Mohanan Nair Anees Thajudeen Narayanan Namboodiri Ajitkumar Valaparambil |
| author_facet | Krishna Kumar Mohanan Nair Anees Thajudeen Narayanan Namboodiri Ajitkumar Valaparambil |
| author_sort | Krishna Kumar Mohanan Nair |
| collection | DOAJ |
| description | A 30year old patient presented to us with recurrent episodes of palpitation and documented tachycardia. In all his presentations a wide QRS tachycardia was recorded. The baseline ECG showed pre excitation. The 12 lead ECG of the tachycardia and the baseline ECG is shown in Fig. 1A. During EP study the patient had baseline pre excitation and the HV interval was 16 ms. A duo-decapolar halo (HL) catheter was used to map right atrium and a decapolar coronary sinus (CS) catheter was used to map coronary sinus. In addition a His bundle and right ventricular (RV) quadripolar catheters were used. The delta wave morphology was suggestive of a posteroseptal pathway. Ventricular pacing from RV apex showing central decremental conduction with ventriculo-atrial Wenkebach at 290 ms. Ventricular extrastimulation also showed decremental conduction and VA block at S1 S2 of 400,240. The intra cardiac recording of tachycardia and its initiation is shown in Fig. 1B. Pacing from lateral RA (HL 5, 6 electrodes) showed progressive pre excitation with extrastimulation and induction of tachycardia. The QRS morphology was same as the patient's clinical tachycardia and the tachycardia cycle length (TCL) was 304 ms. An atrial entrainment protocol showed entrainment with the same QRS morphology while pacing from right atrium. The VA interval of the first return cycle was the same as the subsequent VA intervals. A ventricular entrainment protocol showed V-A-V response and post pacing interval of 414 ms. An atrial extra systole was given from the mid CS electrodes (CS 5, 6) – the effect is shown in Fig. 3. In sinus rhythm a parahisian pacing manoeuvre was done as shown in Fig. 4A. What is the mechanism of the tachycardia and what are the pathways involved? |
| first_indexed | 2024-04-12T13:20:32Z |
| format | Article |
| id | doaj.art-4102c78d7db24cddb12e950e3ad4e2f0 |
| institution | Directory Open Access Journal |
| issn | 0972-6292 |
| language | English |
| last_indexed | 2024-04-12T13:20:32Z |
| publishDate | 2017-03-01 |
| publisher | Elsevier |
| record_format | Article |
| series | Indian Pacing and Electrophysiology Journal |
| spelling | doaj.art-4102c78d7db24cddb12e950e3ad4e2f02022-12-22T03:31:30ZengElsevierIndian Pacing and Electrophysiology Journal0972-62922017-03-01172586210.1016/j.ipej.2017.01.004Wide QRS tachycardia in a patient with pre excitation; what are the pathways involved? Pacing manoeuvres to characterize a unique pathwayKrishna Kumar Mohanan NairAnees ThajudeenNarayanan NamboodiriAjitkumar ValaparambilA 30year old patient presented to us with recurrent episodes of palpitation and documented tachycardia. In all his presentations a wide QRS tachycardia was recorded. The baseline ECG showed pre excitation. The 12 lead ECG of the tachycardia and the baseline ECG is shown in Fig. 1A. During EP study the patient had baseline pre excitation and the HV interval was 16 ms. A duo-decapolar halo (HL) catheter was used to map right atrium and a decapolar coronary sinus (CS) catheter was used to map coronary sinus. In addition a His bundle and right ventricular (RV) quadripolar catheters were used. The delta wave morphology was suggestive of a posteroseptal pathway. Ventricular pacing from RV apex showing central decremental conduction with ventriculo-atrial Wenkebach at 290 ms. Ventricular extrastimulation also showed decremental conduction and VA block at S1 S2 of 400,240. The intra cardiac recording of tachycardia and its initiation is shown in Fig. 1B. Pacing from lateral RA (HL 5, 6 electrodes) showed progressive pre excitation with extrastimulation and induction of tachycardia. The QRS morphology was same as the patient's clinical tachycardia and the tachycardia cycle length (TCL) was 304 ms. An atrial entrainment protocol showed entrainment with the same QRS morphology while pacing from right atrium. The VA interval of the first return cycle was the same as the subsequent VA intervals. A ventricular entrainment protocol showed V-A-V response and post pacing interval of 414 ms. An atrial extra systole was given from the mid CS electrodes (CS 5, 6) – the effect is shown in Fig. 3. In sinus rhythm a parahisian pacing manoeuvre was done as shown in Fig. 4A. What is the mechanism of the tachycardia and what are the pathways involved?http://www.sciencedirect.com/science/article/pii/S0972629216314073Antidromic reciprocating tachycardiaPosteroseptal accessory pathwayEpicardial pathway |
| spellingShingle | Krishna Kumar Mohanan Nair Anees Thajudeen Narayanan Namboodiri Ajitkumar Valaparambil Wide QRS tachycardia in a patient with pre excitation; what are the pathways involved? Pacing manoeuvres to characterize a unique pathway Indian Pacing and Electrophysiology Journal Antidromic reciprocating tachycardia Posteroseptal accessory pathway Epicardial pathway |
| title | Wide QRS tachycardia in a patient with pre excitation; what are the pathways involved? Pacing manoeuvres to characterize a unique pathway |
| title_full | Wide QRS tachycardia in a patient with pre excitation; what are the pathways involved? Pacing manoeuvres to characterize a unique pathway |
| title_fullStr | Wide QRS tachycardia in a patient with pre excitation; what are the pathways involved? Pacing manoeuvres to characterize a unique pathway |
| title_full_unstemmed | Wide QRS tachycardia in a patient with pre excitation; what are the pathways involved? Pacing manoeuvres to characterize a unique pathway |
| title_short | Wide QRS tachycardia in a patient with pre excitation; what are the pathways involved? Pacing manoeuvres to characterize a unique pathway |
| title_sort | wide qrs tachycardia in a patient with pre excitation what are the pathways involved pacing manoeuvres to characterize a unique pathway |
| topic | Antidromic reciprocating tachycardia Posteroseptal accessory pathway Epicardial pathway |
| url | http://www.sciencedirect.com/science/article/pii/S0972629216314073 |
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