Korean Circ J.  2017 Jul;47(4):462-468. 10.4070/kcj.2016.0371.

Local Atrial/Ventricular Ratio as an Adjuvant Marker for Catheter Ablation of Atrioventricular Accessory Pathways

• Kim KH
• Kim DK
• Im HJ
• Seo JS
• Jin HY
• Jang JS
• Yang TH
• Kim DS
• Jeong SY
• Song YS
• Kim DK
• Song PS
• Seol SH
• Kim DI

• KMID: 2392883
• DOI: http://doi.org/10.4070/kcj.2016.0371

Abstract

BACKGROUND AND OBJECTIVES
The earliest atrial (A)/ventricular (V) activation potential, or accessory pathway (AP) potential are commonly used as ablation targets for atrioventricular (AV) APs. However, these targets are sometimes ambiguous.
SUBJECTS AND METHODS
We reviewed 119 catheter ablation cases in 112 patients diagnosed with orthodromic atrioventricular reentrant tachycardia (AVRT) or Wolff-Parkinson-White (WPW) syndrome. Local A/V amplitude potentials with the earliest activation or AP potential were measured shortly before achieving antegrade AP conduction block, ventriculoatrial block during right ventricle (RV) pacing, or AVRT termination with no AP conduction.
RESULTS
APs were located in the left lateral (55.5%), left posterior (17.6%), left posteroseptal (10.1%), midseptal (1.7%), right posteroseptal (7.6%), right posterior (1.7%), and right lateral (5.9%) regions. The mean earliest activation time was 16.7±15.5 ms, mean A/V potential was 1.1±0.9/1.0±0.9 mV, and mean A/V ratio was 1.7±2.0. There was no statistically significant difference between the activation methods (antegrade vs. RV pacing vs. orthodromic AVRT) or AP locations (left vs. right atrium). However, when the local A/V ratio was divided into 3 groups (≤0.6, 1.0±0.3, and ≥1.4), the antegrade approach resulted in an A/V ratio greater than 1.0±0.3 (86.7%, p=0.007), and the orthodromic AVRT state resulted in a ratio of less than 1.0±0.3 (87.5%, p<0.001).
CONCLUSION
The mean local A/V potential and ratio did not differ by activation method or AP location. However, a different A/V ratio based on activation method (≥1.0±0.3, antegrade approach; and ≤1.0±0.3, orthodromic AVRT state) could be a good adjuvant marker for targeting AV APs.

Keyword

Accessory pathway; Catheter ablation; Supraventricular tachycardia; Electrophysiologic technique, cardiac

MeSH Terms

Catheter Ablation*
Catheters*
Electrophysiologic Techniques, Cardiac
Heart Ventricles
Humans
Methods
Tachycardia
Tachycardia, Supraventricular

Figure

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  Fig. 1 The measurement of local A/V ratio for orthodromic atrioventricular reentrant tachycardia using a concealed left lateral AP. (A) AP potential was recorded simultaneously at the ablation catheter and the local CS (1, 2) electrode. Shortly before achieving ventriculoatrial block during right ventricular pacing, the most stable local A/V amplitude potentials with the earliest activation or AP potential were measured at the ablation catheter, for which the values were 1.0/1.2 mV, respectively, and the A/V ratio was 0.8. From top to bottom: surface leads II, aVF, V1, HRA (1: distal, 3: proximal side), CS (1, 2: distal, 9, 10: proximal), RVa d, ABL (D, P). (B) The ablation catheter position during ablation targeting the AP in left anterior oblique view (30 degree) and (C) right anterior oblique view (30 degree). A/V: atrial/ventricular, AP: accessory pathway, CS: coronary sinus, HRA: high right atrium, RVa d: right ventricle apex distal, ABL: ablation, D: distal, P: proximal.

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  Fig. 2 Boxplot of atrial and ventricular amplitude potentials. Each potential was recorded from an ablation catheter at the successful ablation site. I bars represent 95% confidential intervals. Black circles indicate outliers and a star indicates extreme values for outliers.

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