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CASE PRESENTATAION ANDDISCUSSION馬偕紀念醫院 心臟內科A2 祁栢慶
CASE 1
51 y/o female suffered from retrosternal pain, palpitation,
and dizziness for 1 hour and she visited 中興 hospital five months ago,
PSVT was diagnosed (with HR 180/min) and corrected after adenosine injection. She then visited our CV clinic. Thyroid function tests were normal.
Holter EKG: infrequent PVCs Heart echo: mild TR EP study on 101/2/24
BASELINE EKG
RETROGRADE STUDY
Retragrade: dual AVN pathways RV S1S2 induced echo beat (AVNRE)
ANTEGRADE STUDY
Dual AVN pathways RAS1S2: FPERP:380/500 , Jump to slow at 370/500
>50ms
Dual AVN pathways
A2H2=160ms
A2H2=237ms
RAPID RA PACING INDUCED PSVT
RA S1S1 at 260ms with isoprotenerol infusion Tachycardia cycle length: 282ms; VA 33ms
ENTRAINMENT STUDY
TCL: 282ms, PCL: 280ms, Post pacing interval= 408ms PPI- TCL: 408-282 = 126ms
∆ VA>85ms
ENTRAINMENT STUDY
TCL: 291ms, PCL: 270ms, Post pacing interval= 408ms; PPI- TCL: 441-291= 150ms Rapid RV pacing can terminate the tachycardia
ABLATION SITE
ABLATION SITE
Amplitude A:V = 1:5 (Small A and big V) Each ablation: 10 to 20 seconds
JUNCTIONAL RHYTHM DURING ABLATION
Setting: 50W 55⁰C 60s ; Could only reach 47 ⁰C
AFTER ABLATION
AH prolonged to 117-162ms
AFTER ABLATION
AVN WCL: 490ms
AFTER ABLATION
AH interval 213ms CS S1S1 620ms , AH interval 369ms (slow)
POST ABLATION STUDY
Without isoprotenerol: VA dissociation
VA dissociation ~~~
POST ABLATION STUDY
With isoprotenerol: AH came back. AVNERP: 230/500
AFTER ABLATION
With isoprotenerol, VA conduction present Retrograde fast pathway
AFTER ABLATION-
With isoprotenerol infusion CS pacing: AVNRT with longer cycle length
FINAL ABLATION SITE
One last shot…
FINAL ABLATION- ONE LAST SHOT
JR occurred then ablation stopped immediately
(in 5.8seconds)
FINAL ABLATION- ONE LAST SHOT
Second degree AV block, Mobiz type 1.
AFTER FINAL ABLATION
PR interval 288ms First Degree AV block
AFTER FINAL ABLATION-
With isoprotenerol infusion Still AVNRT (slow-fast)
EKG AFTER ABLATION-Day 0
EKG AFTER ABLATION- DAY 7 Day 7
EKG AFTER ABLATION--1MONTHDay 30
DISCUSSION
ABLATION SITE
Each ablation: 10 to 20 seconds Amplitude A:V = 1:5 (Small A and big V)
END POINTS FOR RADIOFREQUENCY DELIVERY Tachycardia rendered noninducible with and without
isoproterenol challenge Elimination or modification of slow pathway function
Elimination of atrium–His bundle (AH) interval jumps Elimination of 1:1 antegrade conduction over the slow
atrioventricular (AV) nodal pathway Retrograde ventricular-atrial block through the slow AV
nodal pathway (fast-slow and slow-slow) AH interval jump with single echoes only (previously
inducible) Fast pathway injury PR interval prolongation (persistent) Transient antegrade AV block after radiofrequency
(caution warranted for further ablation)
PREVENTING ATRIOVENTRICULAR BLOCK
Method Description Comment
Ablation sites below triangle of Koch Inferior to level of CS roof Standard practice
Monitor retrograde junctional conductionDiscontinue RF for loss of 1:1 retrograde conduction
Standard practice
Monitor for rapid junctional rhythm[87] Discontinue RF for junctional rhythm < 350msec
Not prospectively tested
Δ A-A timing His and ablation recordings[112] Difference timing between AEGM His and AEGM ablation site > 20msec
Not prospectively tested
Pace mapping triangle of Koch[113]
Identify site on septum producing shortest stimulus to His time and avoid ablation there
Not prospectively tested
Overdrive atrial pacingPace atrium faster than junctional rate to monitor antegrade conduction
Not prospectively tested
Gradual power titration[114]
Start at 5W and increase power by 5W every 5sec until junctional rhythm, then increase power by 10W for total RF 120sec
Not prospectively tested
Cryoablation 6 or 4mm tip
Thank You Very Much