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At least 19 recordsLinked to original sources

PubMed1991

Sinus node-atrioventricular node isolation: long-term results with the "corridor" operation for atrial fibrillation.

The "corridor" operation is designed to restore sinus rhythm to patients with atrial fibrillation by electrically isolating the sinus node, a band of atrial tissue and the atrioventricular (AV) node from the remaining atrial tissue. Nine patients with drug-refractory atrial fibrillation underwent this operation; four patients had chronic atrial fibrillation and five had paroxysmal atrial fibrillation; the mean duration of symptoms was 12 +/- 8 years. Patient ages ranged from 25 to 68 years (mean 48 +/- 12). At preoperative electrophysiologic study, no patient had evidence of an accessory AV pathway or AV node reentry. Sinus node recovery time could not be determined in five patients because of recurrent atrial fibrillation during or before programmed stimulation. At operation the corridor of atrial tissue connecting the sinus and AV nodes was successfully isolated from the remaining left and right atrial tissue in all patients. One patient required early reoperation for recurrent atrial fibrillation before hospital discharge. At the predischarge electrophysiologic study, the corridor remained isolated in all patients except for one patient who had intermittent conduction between the corridor and excluded right atrium. One patient had nonsustained atrial fibrillation and one had atrial tachycardia evident in the corridor. Atypical AV node reentry of uncertain significance was induced in one other patient. Over a total follow-up of 191 patient months (mean 21 +/- 20), seven patients remained free of atrial fibrillation. Two patients had recurrent atrial fibrillation, which in one patient was effectively controlled by a single antiarrhythmic agent. A permanent pacemaker was implanted in four patients for sinus node dysfunction.(ABSTRACT TRUNCATED AT 250 WORDS)

Arrhythmia, Sinus↗

PubMed1977

De subitaneis mortibus. XXVII. Histological abnormalities in the sinus node, atrioventricular node and His bundle associated with coarctation of the aorta.

A twenty-year-old carpenter died suddenly and unexpectedly nine years after surgical treatment of coarctation of the aorta. Both before and after surgery he had paroxysmal atrial fibrillation, T wave inversions in the ECG and persisting cardiac hypertrophy. At postmortem examination there was focal fibromuscular dysplasia narrowing the sinus node artery, but other small coronary arteries were normal and there was no focal fibrosis of the ventricular myocardium. Within the sinus node there were several small glomera surrounding branches of the sinus node artery. Pericardial fibrosis was present over much of the heart, including margins of the sinus node. The central fibrous body was thickened, particularly on the left, and the His bundle was smaller than normal in cross section. The His bundle appeared displaced toward the right. The artioventricular (A-V) node was split into an upper and lower half tenuously connected through the central fibrous body which divided it. In its lower half the A-V node was directly continuous with ordinary myocardial cells of the interventricular septum. Possible developmental relationships between these unusual anatomical findings in the conduction system and coarctation of the aorta are discussed. How these findings might relate to the known electrophysiological disturbances and some causes for his sudden death are considered.

Adult↗

PubMed1989

The electrophysiological effects of intravenous magnesium on human sinus node, atrioventricular node, atrium, and ventricle.

The effects of intravenously (IV) administered magnesium chloride (MgCl) on electrophysiologic and electrocardiographic variables were studied in 13 patients undergoing a routine electrophysiologic assessment for clinical indications. An infusion of 12 mmol of MgCl was given during a 10-min period and relevant electrophysiologic variables were determined before and after the infusion. Serum Mg levels increased from 0.78 +/- 0.03 (mean +/- SEM) before to 1.52 +/- 0.08 ms after the infusion (p less than 0.0001). Magnesium treatment caused a significant prolongation in PR interval (from 151 +/- 8 to 174 +/- 8 ms, p less than 0.001) as well as in QRS duration (from 90 +/- 4 to 101 +/- 6 ms, p less than 0.05). Likewise, intra-atrial (PA) as well as atrioventricular (AV) nodal (AH) conduction times were significantly prolonged (from 33 +/- 3 to 46 +/- 3 ms, p less than 0.01, and from 85 +/- 6 to 94 +/- 6 ms, p less than 0.05, respectively). Mean effective and functional atrial refractory periods increased (from 228 +/- 8 to 256 +/- 10 ms, p less than 0.01 and from 292 +/- 9 to 320 +/- 11 ms, p less than 0.01, respectively), as did mean AV node functional refractory period (from 399 +/- 29 to 422 +/- 27 ms, p less than 0.02). No significant change occurred with regard to sinus node function (as estimated from heart rate, sinus node recovery time, and calculated sinoatrial conduction time) or ventricular refractoriness. It is concluded that IV Mg has several electrophysiologic effects that may be beneficial in the treatment/prevention of supraventricular tachyarrhythmias.

Adolescent↗

PubMedDate not supplied

Time couse of the blockade effect of propranolol on sinus node and atrioventricular node.

The time course of the blockade effect of propranolol on the sinus node (SN) and the atrioventricular node (AVN) was studied in six normal volunteers. Serial isoproterenol infusions were done before and after oral propranolol administration, 160 mg daily for two days. The inhibition by propranolol of the heart rate increases due to isoproterenol was used to assess the blockade of the sinus node, and the diminution by propranolol of the shortening in the PR interval due to isoproterenol was used to assess the blockade of the atrioventricular node. The blockade effects on the sinus node and the atrioventricular node were identical and persisted more than 24 hours. There was no good relationship between plasma propranolol and blockade effect on sinus node and/or atrioventricular node as propranolol was no longer detectable in the plasma 24 hours after the last dose. A transient hypersensitivity to isoproterenol was present 36 to 48 hours after propranolol withdrawal. The explanation of these phenomena most likely lies in the peculiar nature of beta-adrenergic receptors.

Adult↗

PubMed1975

Origin of the sinoatrial node and atrioventricular node arteries in right, mixed, and left inferior emphasis systems.

The origin of the sinoatrial node artery (SAN) and atrioventricular node artery (AVN) was determined for 118 patients with normal coronary arteriograms. The coronary arteriograms of the 118 patients were divided into right (66.1%), mixed (26.3%), and left (7.6%) inferior emphasis systems. The SAN arose from the right coronary artery in 53%, the left coronary artery in 35%, and had a dual origin in 11%. The proximal right coronary artery was the origin of the SAN in 48.7% of right, 60.5% of mixed, and 55.6% of left inferior emphasis systems. The left coronary artery was the origin of the SAN in 38.5% of right, 25.8% of mixed, and 44.4% of left inferior emphasis systems. The AVN arose from the right coronary artery in 84%, the left coronary artery in 8%, and from both in 8% of the 118 patients. The right coronary artery was the origin of the AVN in 98.7% of right, 74.2% of mixed, and 0% of left inferior emphasis systems. The left coronary artery was the origin of the AVN in 0% of right, 25.8% of mixed, and 100% of left inferior emphasis systems.

Adult↗

PubMed1990

[Different sensitivity of sinus node and atrioventricular node to adenosine triphosphate].

We showed that higher concentration of adenosine 5'-triphosphate (ATP) was required to prolong the spontaneous cycle length of the sinus node (SN) than that required to prolong the spontaneous cycle length of the atrioventricular node (AVN). Spontaneously beating preparations of SN and AVN of rabbit (n = 8) were superfused with Tyrode solution containing 10(-8)-10(-3)M ATP, and action potential was recorded. The negative chronotropic action of ATP was dependent on the concentration. The required concentration of ATP to prolong spontaneous cycle length significantly (p less than 0.01) was 10(-5)M in SN and 10(-6)M in AVN, respectively. At concentrations higher than 10(-6)M, the degree of prolongation was greater in AVN than in SN (p less than 0.01). 10(-7)M dipyridamole enhanced this effect of ATP, while 10(-4)M theophylline reduced it. Action potential duration of 50% repolarization was not changed significantly in either SN or AVN at concentrations up to 10(-3)M. Maximum diastolic potential (MDP) was hyperpolarized from 10(-8)M to 10(-4) M. Hyperpolarization of MDP induced by ATP was greater in AVN than in SN but it was not statistically significant. MDP was depolarized by 10(-3) M ATP in both SN and AVN. The maximum velocity of depolarization was slightly larger in both SN and AVN as the concentration of ATP was increased in the perfusate. However, it was not statistically significant. 10(-3) M ATP decreased the maximum velocity of depolarization.(ABSTRACT TRUNCATED AT 250 WORDS)

Action Potentials↗

PubMed1991

The use of two-dimensional echocardiography during catheter ablation of the atrioventricular node.

Atrioventricular nodal catheter ablation has proved an effective option in patients with drug-refractory, uncontrolled, supraventricular tachyarrhythmias; however, many complications in the immediate post ablative period relate to direct myocardial damage due to the electrical current generated by the catheter. The authors used two-dimensional echocardiography in a 57-year-old female patient with recurrent uncontrolled rapid ventricular rates despite multiple antiarrhythmic medications, in an attempt to identify the sequence of events responsible for complications of the ablation procedure. The echocardiographic images showed evidence of an explosion: microbubbles outlining an expanding force were seen which, if contained in a confined space such as the coronary sinus, might explain previously observed mechanical damage. Two-dimensional echocardiography may be useful for continual monitoring of catheter position during ablation.

Arrhythmias, Cardiac↗

PubMed1992

Surgery for atrioventricular node reentry tachycardia. Results with surgical skeletonization of the atrioventricular node and discrete perinodal cryosurgery.

Surgical treatment options for interruption of atrioventricular node reentrant tachycardia include (1) skeletonization of the atrioventricular node by dissecting it from most of its atrial inputs and (2) discrete cryosurgery of the perinodal tissues by applying a series of sequential cryolesions to the atrial tissues immediately adjacent to the atrioventricular node. Both these techniques attempt to interrupt one of the dual atrioventricular node conduction pathways while preserving the other. This report describes 17 consecutive patients who underwent surgical treatment, 10 patients with skeletonization of the atrioventricular node and seven patients with discrete perinodal cryosurgery. There were 10 female and seven male patients and their ages ranged from 28 to 56 years (mean 38). Two of the 17 patients had Wolff-Parkinson-White syndrome and their accessory pathways were interrupted before the atrioventricular nodal reentrant tachycardia was ablated. All the procedures were performed in a normothermic beating heart while atrioventricular conduction was monitored closely. In the skeletonization technique, the right atrial septum was mobilized and the atrioventricular node exposed anterior to the tendon of the Todaro. The perinodal cryosurgical procedure was also performed through a right atriotomy and a series of sequential 3 mm cryolesions were placed around the borders of the triangle of Koch on the inferior right atrial septum. There were no operative deaths. Two patients who underwent the skeletonization operation had heart block necessitating pacemaker therapy. At postoperative electrophysiologic study, no echoes or atrioventricular nodal reentrant tachycardia were inducible in any of the 17 patients. All patients have remained free of arrhythmia recurrence and have required no antiarrhythmic therapy after a follow-up of 5 to 28 months (mean 14). In conclusion, both atrioventricular node skeletonization and perinodal cryosurgery successfully ablate atrioventricular nodal reentrant tachycardia; however, perinodal cryosurgery appears to be safer in avoiding heart block, is more easily performed, and is our procedure of choice for the management of medically refractory atrioventricular nodal reentrant tachycardia.

Adolescent↗

PubMed1979

Effect of hypoxia on the sinoatrial node, atrium, and atrioventricular node in the rabbit heart.

We used intracellular microelectrodes to study the effects of hypoxia on the isolated, superfused sinoatrial (SA) node, atrium, and atrioventricular (AV) node of the rabbit heart. Hypoxia decreased the rate of spontaneous impulse initiation in SA nodal fibers by decreasing the slope of diastolic depolarization. With gradually decreasing Po2, the sinus rate was reduced; concomitantly, the corrected sinus node recovery time after rapid atrial stimulation was much less affected demonstrating marked prolongation only under severe anoxic conditions. Hypoxia decreased the amplitude of action potentials of the SA node and of the AV node but not of the atrium. SA and AV nodal conduction were slowed by hypoxia; intraatrial conduction was not significantly affected. AV nodal conduction block occurred at lower atrial rates, and the effective refractory period of the AV node was prolonged. Inhomogeneity of SA and AV nodal impulse propagation often was observed in the presence of hypoxia. This was associated with concealed reentry within both nodal areas. The extracellular K+ concentration of the atrial tissue was measured with ion-sensitive microelectrodes. [K+]o remained unchanged even after prolonged periods of severe hypoxia. These results are consistent with the hypothesis that acute hypoxia predominantly inhibits slow response activity but has only little effect on the fast inward sodium current.

Action Potentials↗

PubMed1989

Role of intravenous isoproterenol in the electrophysiologic induction of atrioventricular node reentrant tachycardia in patients with dual atrioventricular node pathways.

To assess the role of intravenous isoproterenol for the facilitation of electrophysiologic induction of atrioventricular (AV) node reentrant tachycardia, 20 patients with dual AV node pathways who lacked inducible AV node reentrant tachycardia at control study had a constant isoproterenol infusion administered and underwent repeat study. Six (30%) of 20 patients (group I) had inducible AV node reentrant tachycardia during isoproterenol infusion whereas the other 14 (70%) patients (group II) did not. Paroxysmal supraventricular tachycardia was clinically documented in all 6 group I patients compared to 3 (21%) of 14 group II patients (p = 0.002). The sensitivity and specificity of isoproterenol-facilitated induction of AV node reentrant tachycardia were 67 and 100%, respectively. The isoproterenol-facilitated induction of sustained AV node reentry was mediated by resolution of the weak link in anterograde slow pathway in 2 (33%) patients, in retrograde fast pathway in 3 (50%) and in both anterograde slow and retrograde fast pathways in 1 (17%) patient. Four group I patients were given intravenous propranolol, 0.2 mg/kg body weight, and had complete suppression of isoproterenol-facilitated induction of AV node reentry. Thus, intravenous isoproterenol is a rather sensitive and highly specific adjunct to electrophysiologic induction of AV node reentrant tachycardia in patients with dual AV node pathways but without inducible sustained AV node reentry.

Adrenergic beta-Antagonists↗

PubMed1989

Direct surgical treatment of atrioventricular node reentrant tachycardia.

Atrioventricular node reentry tachycardia is a common type of supraventricular tachycardia. Rarely is it incapacitating and refractory to drug therapy, but when it is, the only option in therapy until recently has been atrioventricular node ablation or antitachycardia pacemaker insertion. The purpose of this paper is to review the case histories of four patients in whom we have surgically abolished atrioventricular node reentrant tachycardia while intentionally preserving atrioventricular node conduction. All four patients had atrioventricular node reentrant tachycardia confirmed by electrophysiologic study as diagnosed by established criteria. One patient had a left posterior atrioventricular accessory pathway, in addition to atrioventricular node reentrant tachycardia. All patients underwent intraoperative epicardial and endocardial mapping. Direct surgical dissection of the atrioventricular node node was performed in all four patients during normothermic cardiopulmonary bypass. Early and late postoperative electrophysiologic studies were used to evaluate the success of the surgical dissection. None of the patients had any evidence of dual atrioventricular node pathways or spontaneous or inducible atrioventricular node reentrant tachycardia postoperatively. At last follow-up (15 weeks to 21 months postoperatively), all patients were free from arrhythmias and cardiac medications, all were in normal sinus rhythm, and all had a subjectively improved life-style. This technique of direct surgical dissection of the atrioventricular node during normothermic cardiopulmonary bypass has allowed for complete cure of atrioventricular node reentrant tachycardia, while maintaining normal atrioventricular node function in these four patients.

Adult↗

PubMed1992

Comparison of the cost of radiofrequency catheter modification of the atrioventricular node and medical therapy for drug-refractory atrioventricular node reentrant tachycardia.

The purpose of this study was to determine the charges for radiofrequency catheter modification of the atrioventricular (AV) node in 15 patients with symptomatic AV node reentrant tachycardia despite pharmacologic therapy and to compare these charges with the estimated charges for health care utilization by the same patients before the catheter procedure was performed. There were seven men and eight women with a mean age of 50 +/- 17 years. The mean duration and frequency of symptoms were 16 +/- 9 years and 4.5 +/- 6 episodes/month, respectively. Fourteen of the 15 patients required only one procedure for diagnosis and cure of AV node reentrant tachycardia and 1 patient required two sessions. All patients underwent electrophysiologic study before discharge from the hospital to confirm the short-term efficacy of the procedure. The mean duration of the hospital stay was 3 +/- 1.5 days and the mean total charge/patient expressed in 1991 dollars was $15,893 +/- $3,338 for catheter modification. These total charges consisted of hospital charges of $8,105 +/- $2,466 and physician charges of $7,788 +/- $971. All patients had a successful outcome and required no additional antiarrhythmic therapy. The estimated cost of health care utilization for these 15 patients before cure of AV node reentrant tachycardia was $7,651/patient per year. These estimated costs included charges incurred for emergency room visits, office visits, hospitalizations and antiarrhythmic drug therapy. In conclusion, the results of this study indicate that the annual health care costs incurred by patients who have symptomatic, drug-refractory paroxysmal supraventricular tachycardia caused by AV node reentry are substantial.(ABSTRACT TRUNCATED AT 250 WORDS)

Anti-Arrhythmia Agents↗

PubMed1985

Examination of an exponential model of conduction through the human atrioventricular node.

The atrioventricular node (AVN) has been modeled by relating output (A2H2 or H1H2) to input (A1A2) where A and H are atrial and His bundle electrograms during fixed rate atrial pacing (A1A1) or with an extrastimulus (A2). (Formula: see text) This study examined this model in 61 nonselected patients, specifically for AVN (in)stability and the possibility of multiple pathways. After programmed atrial stimulation at two basic cycle lengths of 600 ms and 462 ms, A1H1, A2H2 and H1H2 were digitized and plotted as a function of A1A2. Seven of 104 trials were rejected as SD. A1H1 was greater than 15 ms, suggesting AVN instability. Another 26 and 34 plots, respectively, of A2H2 and H1H2 were rejected because of inadequate data. In the remainder, goodness of fit of the single exponentials was tested statistically in three ways: R2, the runs test, and the Kendall rank coefficient test. Results were compared with an electrophysiologist who examined plots for one or more pathways (either discontinuous curves or slope change in a continuous curve). Single exponentials were successfully fitted (by runs test) in 44/71 and 34/63 of A2H2 and H1H2 plots, respectively, usually in accordance with the cardiologist. Discordance between computations and the cardiologist could be attributed to data scatter and lack of a sufficiently rigid stimulation protocol. The identification of bifurcation points in the presence of multiple pathways, particularly when manifest as a change in slope (approximately 6% of trials) rather than discontinuity of plots (approximately 20% of trials) remains an outstanding problem.

Adolescent↗

PubMed1979

Incidence, determinants and significance of fixed retrograde conduction in the region of the atrioventricular node. Evidence for retrograde atrioventricular nodal bypass tracts.

Of 104 consecutive patients studied in our laboratory with His bundle electrograms, atrial and ventricular pacing and the atrial and ventricular extrastimulus techniques, 18 patients in whom the existence and utilization of ventriculoatrial (V-A) bypass tracts were excluded demonstrated evidence for fixed and rapid retrograde conduction in the region of the atrioventricular node (A-V) as suggested by the following: (1) short (36 +/- 2 msec [mean +/- standard error of mean]) and constant retrograde H2-A2 intervals during retrograde refractory period studies; (2) significantly (P less than 0.025) better V-A than A-V conduction; (3) significantly (P less than 0.025) shorter retrograde functional refractory period of the V-A conducting system than of the A-V conduction system; and (4) the retrograde effective refractory period of the A=V nodal region was not attainable in any of the 18 patients. Fourteen of the 18 patients (77 percent) had a history of palpitations and 10 (51 percent) had documented paroxysmal supraventricular tachycardia; in 13 (72 percent) single echoes or sustained reentrant supraventricular tachycardia, or both, could be induced during atrial pacing or atrial premature stimulation studies, or both. During tachycardia all these 13 patients had a short (37 +/- 2.4 msec) and constant conduction time in the retrograde limb (H-Ae interval) of the reentrant circuit that was identical to the H2-A2 interval. In conclusion, fixed and rapid retrograde conduction in the region of the A-V node (1) is seen in approximately 17 percent of patients, (2) is associated with a large incidence of reentrant paroxysmal supraventricular tachycardia, and (3) suggests the presence of A-V nodal bypass tracts (intranodal or extranodal functioning in retrograde manner).

Adult↗

PubMed1979

Morphology of the atrioventricular node, bundle and proximal bundle branches: a study employing computerized reconstruction.

The morphology of the human atrioventricular node, atrioventricular bundle and bundle branches is described. A block of tissue bounded by the ostium of the coronary sinus, the pars membranacea, the septal leaflet of the tricuspid valve and the atrial and ventricular septa is removed. The block is then sectioned serially from the right endocardial surface in the frontal plane of the heart. Sectioning in this way produces fewer sections than from techniques previously described. Outlines of the atrioventricular node, atrioventricular bundle and proximal bundle branches are digitally registered and stored in a computer. Three dimensional reconstructions of the structures are then generated by computer and displayed on an oscilloscope so that the entire three dimensional image can be rotated in any plane. Stereoscopic image pairs are produced to assist perception of the shape of the atrioventricular node, bundle and branching patterns of the bundles. This technique is unique in that it describes a method from which a relatively small number of histologic sections are generated permitting not only a complete histologic examination, but also a study of the morphology of the area.

Adult↗

PubMed1990

Perinodal cryosurgery for atrioventricular node reentry tachycardia in 23 patients.

Atrioventricular node reentry tachycardia is the most common cause of paroxysmal supraventricular tachycardia. Available nonpharmacologic therapies include (1) catheter ablation or cryosurgical ablation of the His bundle and insertion of a permanent pacemaker and (2) surgical dissection around the atrioventricular node or discrete cryosurgery of the perinodal tissues, in an attempt to divide or ablate only one of the dual atrioventricular node conduction pathways responsible for the tachycardia while leaving the other intact. This report describes 23 consecutive patients who underwent the discrete cryosurgical procedure between August 13, 1982, and March 16, 1989. The first patient in this series, a 38-year-old woman, is the first patient in whom refractory atrioventricular node reentry tachycardia was cured surgically by a procedure designed to treat this arrhythmia. The ages of the 13 female and 10 male patients ranged from 12 to 56 years with an average age of 29 years. Fourteen of the 23 patients (61%) had the Wolff-Parkinson-White syndrome. Other associated arrhythmias included atrial flutter/fibrillation (n = 2), right atrial reentrant tachycardia (n = 1), junctional tachycardia (n = 1), and a Mahaim fiber (n = 1). Associated anatomic abnormalities included Ebstein's anomaly in two patients and a large right atrial aneurysm in one patient. The perinodal cryosurgical procedure was performed through a right atriotomy in the normothermic beating heart. Multiple 3 mm diameter cryolesions were placed around the borders of the triangle of Koch on the lower right atrial septum to alter the input pathways of the atrioventricular node. There were no operative deaths in this series of patients. Postoperatively, all 23 patients had normal atrioventricular conduction, and no heart block has occurred in any patients during the follow-up period. All patients have remained free of atrioventricular node reentry tachycardia (and of the Wolff-Parkinson-White syndrome) and none has required postoperative antiarrhythmic drugs for either of these arrhythmias. We consider this simple, safe, easily performed, and uniformly successful operation to be the procedure of choice for the treatment of medically refractory atrioventricular node reentry tachycardia.

Adolescent↗

PubMed1985

Transient outward current carried by potassium and sodium in quiescent atrioventricular node cells of rabbits.

Single atrioventricular node cells were dispersed by treating the rabbit heart with collagenase. In Tyrode's solution, the cells became rounded, and about 20% of them showed spontaneous activity, whereas the rest remained quiescent. When those quiescent cells were whole-cell clamped, depolarizing clamp pulses from the holding potential of -83 mV induced an outward current which decayed quickly, with a time course similar to that of the transient outward current in the Purkinje fiber. The amplitude of the current became larger when progressively more positive clamp pulses were given from a very negative holding potential. The inactivation time course of this current consisted of two exponential components. Single-channel current recordings from those cells revealed a class of channels that activated more frequently during the initial part of depolarizing pulses. Summation of those unitary currents reproduced activation and inactivation time courses of the macroscopic current well, suggesting that this channel corresponds to the transient outward current. The current-voltage relationship of the channel was linear with the slope conductance of 19.9 +/- 1.8 pS (n = 7), and the reversal potential was near the resting potential of the atrioventricular node cell with 5.4 mM potassium chloride and 134.6 mM sodium chloride in the pipette. The channel was passing mainly potassium ions, but sodium ions also seemed to carry a fraction of the current. The possible role of the transient outward current in the quiescent node cell is discussed.

Animals↗

PubMed1989

Percutaneous catheter modification of the atrioventricular node. A potential cure for atrioventricular nodal reentrant tachycardia.

Our purpose was to describe a technique of atrioventricular (AV) node modification for patients with drug refractory AV nodal reentrant tachycardia (AVNRT). Nine patients (mean age, 45 +/- 20; range, 14-82) with recurrent drug refractory AVNRT (n = 8) or sudden cardiac death thought to be precipitated by AVNRT (n = 1) underwent a percutaneous catheter procedure to modify AV nodal function. The area between the electrode recording the maximal His-bundle electrogram and the ostium of the coronary sinus was divided into three zones. Perinodal direct current shocks of 100-300 J were delivered to one (n = 2), two (n = 3), or three (n = 4) zones without complications. The procedure endpoints were modification of AV conduction (either first degree AV block or complete retrograde ventriculo-atrial [VA] block) and failure to induce AVNRT before or after isoproterenol and/or atropine administration. Six of nine patients (67%) have had no inducible or spontaneous AVNRT over a mean follow-up of 12.3 +/- 4.1 months (range, 4.5-17). One of the six underwent repeat, successful modification, because AVNRT was inducible at restudy 2 days after the initial procedure. AVNRT recurred in three patients (33%), one early (3 days) and two late (3-4 months). Two of these patients underwent complete ablation of the AV junction and permanent pacemaker placement, whereas one is controlled with drug therapy. Therefore, AV nodal modification resulted in tachycardia control without antiarrhythmic drugs in six of nine (67%) and obviated the need for complete AV junctional ablation in seven of nine patients (78%). Elimination of AVNRT appears to result from either block in the retrograde fast pathway or modification of the antegrade slow pathway, such that AVNRT cannot be sustained. Additional findings suggest that an atrio-Hisian accessory connection may not be involved in AVNRT in some of these patients. Percutaneous catheter AV nodal modification appears to be a promising technique for treatment of refractory AVNRT and may obviate need for complete AV junctional ablation in a substantial number of patients with drug/pacemaker refractory AVNRT.

Adult↗