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An unusual atrioventricular accessory pathway with an oblique course

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1 An unusual atrioventricular accessory pathway with an oblique course
Xin-hua Wang, MD, Zheng Li, MD, Ben He, MD, PhD  HeartRhythm Case Reports  Volume 1, Issue 6, Pages (November 2015) DOI: /j.hrcr Copyright © 2015 Heart Rhythm Society Terms and Conditions

2 Figure 1 A: Wolff-Parkinson-White syndrome prior to ablation; B: Disappearance of preexcitation on postprocedural electrocardiogram. HeartRhythm Case Reports 2015 1, DOI: ( /j.hrcr ) Copyright © 2015 Heart Rhythm Society Terms and Conditions

3 Figure 2 A: the earliest ventricular activation at coronary sinus (CS) proximal electrode pair 5-6 (CS5-6) in sinus rhythm. B: Supraventricular tachycardia 1 (SVT1) with the earliest atrial activation at CS1-2 and the second earliest at CS9-10 (dotted line as a caliper). C: A retrograde A wave at CS1-2 was markedly delayed during right ventricular apex (RVa) pacing after ablation of 1 atrial end of AP at the lateral mitral annulus (MA). D: The atrial activation sequence of supraventricular tachycardia 2 (SVT2) was similar to that during RVa pacing after ablation of 1 branch of AP. E and F: The upper parts of E and F show the schematic diagrams delineating the CS atrial activation sequence during SVT1 and SVT2, respectively. The lower parts of E and F show CS recordings of atrial activation during SVT1 and SVT2, respectively. In the lower parts of E and F, the solid straight arrow represents conduction sequence of potential of accessory pathways. (PAPs). The dotted straight arrow represents atrial activation sequence. Note the sharp PAP preceding the A wave on each CS tracing and the different atrial activation sequences during SVT1 and SVT2. G: Persistent preexcitation despite apparent atrioventricular conduction delay on CS recordings. H: marked atrioventricular conduction delay and abolishment of preexcitation on ECG. I: A complete ventriculoatrial conduction block during RVa pacing after successful ablation of AP. HeartRhythm Case Reports 2015 1, DOI: ( /j.hrcr ) Copyright © 2015 Heart Rhythm Society Terms and Conditions

4 Figure 3 A fluoroscopic image of catheter positioning. A: The successful transseptal ablation of 1 branch of AP at lateral MA (left anterior oblique 45° view); B: An ablation failure on the ventricular side of the posterolateral MA via transaortic route (right anterior oblique 30° view); C: The successful transseptal ablation of the other branch of AP at the very posterolateral MA. The white rings in A and C represent the MA. ABL = ablation catheter; MA = mitral annulus. HeartRhythm Case Reports 2015 1, DOI: ( /j.hrcr ) Copyright © 2015 Heart Rhythm Society Terms and Conditions

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