The "hidden" concealed left-sided accessory pathway

An uncommon cause of SVT in young people

Robert H. Pass, Leonardo Liberman, Eric S. Silver, Christopher M. Janson, Andrew D. Blaufox, Lynn Nappo, Scott R. Ceresnak

Research output: Contribution to journalArticle

2 Citations (Scopus)

Abstract

Background: Concealed left-sided accessory pathways (CLAP) are a cause of supraventricular tachycardia (SVT) in the young. Most are mapped with right ventricular (RV) apical/outflow pacing. Rarely, alternative means of mapping are required. We review our experience from three pediatric electrophysiology (EP) centers with a rare form of "hidden" CLAP. Methods: All patients <21 years undergoing EP study from 2008 to 2014 with a "hidden" CLAP (defined as an accessory pathway [AP] for which RV pacing at cycle lengths [CL] stable for mapping did not demonstrate eccentric retrograde conduction) were included. Exclusion criteria: preexcitation. Demographic, procedural, and follow-up data were collected. Results: A total of 23 patients met the criteria (median age, 14.3 years [range 7-21], weight, 51 kg [31-99]). 21 (96%) had SVT and one AFIB (4%). APs were adenosine sensitive in 7/20 patients (35%) and VA conduction was decremental in six (26%). CLAP conduction was demonstrable with orthodromic reentrant tachycardia in all patients, with RV extrastimulus testing in seven (30%) and with rapid RV pacing (<CL 300) in three (13%). Left ventricular (LV) pacing demonstrated CLAP conduction in 17/17 (100%) patients in whom it was used. All 23 CLAPs were successfully ablated (100%) via transseptal approach with radiofrequency energy. Specific ablation techniques included: 16 (70%) during LV paced rhythm, four (17%) during orthodromic reciprocating tachycardia (ORT; 3/4 ventricular entrained), and three (13%) with brief rapid RV pacing. There were no complications. At 18 months (range 3-96), there was one recurrence (4%). Conclusions: Some CLAPs are only demonstrable with LV pacing, entrained ORT, or rapid RV pacing. LV pacing facilitated preferential AP conduction, allowing for mapping while maintaining stable hemodynamics.

Original languageEnglish (US)
JournalPACE - Pacing and Clinical Electrophysiology
DOIs
StateAccepted/In press - Jan 1 2018

Fingerprint

Supraventricular Tachycardia
Electrophysiology
Reciprocating Tachycardia
Ablation Techniques
Patient Rights
Tachycardia
Adenosine
Hemodynamics
Demography
Pediatrics
Weights and Measures
Recurrence

Keywords

  • Accessory pathway
  • Orthodromic reciprocating tachycardia
  • Pediatrics
  • Supraventricular tachycardia

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

Cite this

The "hidden" concealed left-sided accessory pathway : An uncommon cause of SVT in young people. / Pass, Robert H.; Liberman, Leonardo; Silver, Eric S.; Janson, Christopher M.; Blaufox, Andrew D.; Nappo, Lynn; Ceresnak, Scott R.

In: PACE - Pacing and Clinical Electrophysiology, 01.01.2018.

Research output: Contribution to journalArticle

Pass, Robert H. ; Liberman, Leonardo ; Silver, Eric S. ; Janson, Christopher M. ; Blaufox, Andrew D. ; Nappo, Lynn ; Ceresnak, Scott R. / The "hidden" concealed left-sided accessory pathway : An uncommon cause of SVT in young people. In: PACE - Pacing and Clinical Electrophysiology. 2018.
@article{fb75115113904fe8aaac2dcf090d748e,
title = "The {"}hidden{"} concealed left-sided accessory pathway: An uncommon cause of SVT in young people",
abstract = "Background: Concealed left-sided accessory pathways (CLAP) are a cause of supraventricular tachycardia (SVT) in the young. Most are mapped with right ventricular (RV) apical/outflow pacing. Rarely, alternative means of mapping are required. We review our experience from three pediatric electrophysiology (EP) centers with a rare form of {"}hidden{"} CLAP. Methods: All patients <21 years undergoing EP study from 2008 to 2014 with a {"}hidden{"} CLAP (defined as an accessory pathway [AP] for which RV pacing at cycle lengths [CL] stable for mapping did not demonstrate eccentric retrograde conduction) were included. Exclusion criteria: preexcitation. Demographic, procedural, and follow-up data were collected. Results: A total of 23 patients met the criteria (median age, 14.3 years [range 7-21], weight, 51 kg [31-99]). 21 (96{\%}) had SVT and one AFIB (4{\%}). APs were adenosine sensitive in 7/20 patients (35{\%}) and VA conduction was decremental in six (26{\%}). CLAP conduction was demonstrable with orthodromic reentrant tachycardia in all patients, with RV extrastimulus testing in seven (30{\%}) and with rapid RV pacing (<CL 300) in three (13{\%}). Left ventricular (LV) pacing demonstrated CLAP conduction in 17/17 (100{\%}) patients in whom it was used. All 23 CLAPs were successfully ablated (100{\%}) via transseptal approach with radiofrequency energy. Specific ablation techniques included: 16 (70{\%}) during LV paced rhythm, four (17{\%}) during orthodromic reciprocating tachycardia (ORT; 3/4 ventricular entrained), and three (13{\%}) with brief rapid RV pacing. There were no complications. At 18 months (range 3-96), there was one recurrence (4{\%}). Conclusions: Some CLAPs are only demonstrable with LV pacing, entrained ORT, or rapid RV pacing. LV pacing facilitated preferential AP conduction, allowing for mapping while maintaining stable hemodynamics.",
keywords = "Accessory pathway, Orthodromic reciprocating tachycardia, Pediatrics, Supraventricular tachycardia",
author = "Pass, {Robert H.} and Leonardo Liberman and Silver, {Eric S.} and Janson, {Christopher M.} and Blaufox, {Andrew D.} and Lynn Nappo and Ceresnak, {Scott R.}",
year = "2018",
month = "1",
day = "1",
doi = "10.1111/pace.13279",
language = "English (US)",
journal = "PACE - Pacing and Clinical Electrophysiology",
issn = "0147-8389",
publisher = "Wiley-Blackwell",

}

TY - JOUR

T1 - The "hidden" concealed left-sided accessory pathway

T2 - An uncommon cause of SVT in young people

AU - Pass, Robert H.

AU - Liberman, Leonardo

AU - Silver, Eric S.

AU - Janson, Christopher M.

AU - Blaufox, Andrew D.

AU - Nappo, Lynn

AU - Ceresnak, Scott R.

PY - 2018/1/1

Y1 - 2018/1/1

N2 - Background: Concealed left-sided accessory pathways (CLAP) are a cause of supraventricular tachycardia (SVT) in the young. Most are mapped with right ventricular (RV) apical/outflow pacing. Rarely, alternative means of mapping are required. We review our experience from three pediatric electrophysiology (EP) centers with a rare form of "hidden" CLAP. Methods: All patients <21 years undergoing EP study from 2008 to 2014 with a "hidden" CLAP (defined as an accessory pathway [AP] for which RV pacing at cycle lengths [CL] stable for mapping did not demonstrate eccentric retrograde conduction) were included. Exclusion criteria: preexcitation. Demographic, procedural, and follow-up data were collected. Results: A total of 23 patients met the criteria (median age, 14.3 years [range 7-21], weight, 51 kg [31-99]). 21 (96%) had SVT and one AFIB (4%). APs were adenosine sensitive in 7/20 patients (35%) and VA conduction was decremental in six (26%). CLAP conduction was demonstrable with orthodromic reentrant tachycardia in all patients, with RV extrastimulus testing in seven (30%) and with rapid RV pacing (<CL 300) in three (13%). Left ventricular (LV) pacing demonstrated CLAP conduction in 17/17 (100%) patients in whom it was used. All 23 CLAPs were successfully ablated (100%) via transseptal approach with radiofrequency energy. Specific ablation techniques included: 16 (70%) during LV paced rhythm, four (17%) during orthodromic reciprocating tachycardia (ORT; 3/4 ventricular entrained), and three (13%) with brief rapid RV pacing. There were no complications. At 18 months (range 3-96), there was one recurrence (4%). Conclusions: Some CLAPs are only demonstrable with LV pacing, entrained ORT, or rapid RV pacing. LV pacing facilitated preferential AP conduction, allowing for mapping while maintaining stable hemodynamics.

AB - Background: Concealed left-sided accessory pathways (CLAP) are a cause of supraventricular tachycardia (SVT) in the young. Most are mapped with right ventricular (RV) apical/outflow pacing. Rarely, alternative means of mapping are required. We review our experience from three pediatric electrophysiology (EP) centers with a rare form of "hidden" CLAP. Methods: All patients <21 years undergoing EP study from 2008 to 2014 with a "hidden" CLAP (defined as an accessory pathway [AP] for which RV pacing at cycle lengths [CL] stable for mapping did not demonstrate eccentric retrograde conduction) were included. Exclusion criteria: preexcitation. Demographic, procedural, and follow-up data were collected. Results: A total of 23 patients met the criteria (median age, 14.3 years [range 7-21], weight, 51 kg [31-99]). 21 (96%) had SVT and one AFIB (4%). APs were adenosine sensitive in 7/20 patients (35%) and VA conduction was decremental in six (26%). CLAP conduction was demonstrable with orthodromic reentrant tachycardia in all patients, with RV extrastimulus testing in seven (30%) and with rapid RV pacing (<CL 300) in three (13%). Left ventricular (LV) pacing demonstrated CLAP conduction in 17/17 (100%) patients in whom it was used. All 23 CLAPs were successfully ablated (100%) via transseptal approach with radiofrequency energy. Specific ablation techniques included: 16 (70%) during LV paced rhythm, four (17%) during orthodromic reciprocating tachycardia (ORT; 3/4 ventricular entrained), and three (13%) with brief rapid RV pacing. There were no complications. At 18 months (range 3-96), there was one recurrence (4%). Conclusions: Some CLAPs are only demonstrable with LV pacing, entrained ORT, or rapid RV pacing. LV pacing facilitated preferential AP conduction, allowing for mapping while maintaining stable hemodynamics.

KW - Accessory pathway

KW - Orthodromic reciprocating tachycardia

KW - Pediatrics

KW - Supraventricular tachycardia

UR - http://www.scopus.com/inward/record.url?scp=85042350322&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=85042350322&partnerID=8YFLogxK

U2 - 10.1111/pace.13279

DO - 10.1111/pace.13279

M3 - Article

JO - PACE - Pacing and Clinical Electrophysiology

JF - PACE - Pacing and Clinical Electrophysiology

SN - 0147-8389

ER -