A wide QRS complex tachycardia utilizing an atypical accessory pathway in latent Wolff- Parkinson-White syndrome: Manifestation of anterograde conduction.

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A wide QRS complex tachycardia utilizing an atypical accessory pathway in latent Wolff- Parkinson-White syndrome: Manifestation of anterograde conduction during atrial fibrillation without delta waves in sinus rhythm Toshihiro Nakamura, MD, Koji Fukuzawa, MD, Jun Kurose, MD, Hideya Suehiro, MD, Kensuke Matsumoto, MD, Ken-ichi Hirata, MD, PhD HeartRhythm Case Reports Volume 5, Issue 8, Pages 419-423 (August 2019) DOI: 10.1016/j.hrcr.2019.05.001 Copyright © 2019 Heart Rhythm Society Terms and Conditions

Figure 1 A: A 12-lead electrocardiogram (ECG) exhibiting a wide QRS irregular tachycardia suspected to be atrial fibrillation with a rapid ventricular response. B: The resting 12-lead ECG during sinus rhythm exhibited no delta waves. The heart rate was 49 beats per minute and PR interval 149 ms. HeartRhythm Case Reports 2019 5, 419-423DOI: (10.1016/j.hrcr.2019.05.001) Copyright © 2019 Heart Rhythm Society Terms and Conditions

Figure 2 Resting 12-lead electrocardiogram post ablation procedure. The heart rate was 55 beats per minute and PR interval 173 ms. No septal Q waves were recognized. HeartRhythm Case Reports 2019 5, 419-423DOI: (10.1016/j.hrcr.2019.05.001) Copyright © 2019 Heart Rhythm Society Terms and Conditions

Figure 3 Accessory pathway (AP) mapping was performed during coronary sinus ostium (CSo) pacing at 150 ppm based on the prematurity of the AP potential and ventricular activation potential (V). The location markers recorded by the EnSite NavX system (St. Jude Medical, St. Paul, MN) are shown on the electroanatomical map. Site A is the site where transient block was obtained, and site C is the site of the successful ablation. The stimulus-AP intervals at sites A, B, and C were 125 ms, 135 ms, and 144 ms, respectively. The shortest AP-V interval was recorded at the successful site C. On the electroanatomical map, the wavy arrow indicates the slow conduction over the AP. The straight arrow indicates the relatively fast conduction over the normal myocardium. The anatomical distance between the AP fiber and each ablation site (dotted straight lines) gradually became closer as the ablation catheter came closer to the successful ablation site C. The solid line indicates the pathway proven during the electrophysiological study and the dotted line indicates the speculated pathway. The catheter position is shown in the fluoroscopic image and each red circle indicates the ablation site (sites A and C). ABL = ablation catheter; CS = coronary sinus; CSo = coronary sinus ostium; His = His potential site; HRA = high right atrium; LAO = left anterior oblique; RA = right atrium; RAO = right anterior oblique; RV = right ventricle. HeartRhythm Case Reports 2019 5, 419-423DOI: (10.1016/j.hrcr.2019.05.001) Copyright © 2019 Heart Rhythm Society Terms and Conditions