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Arrhythmias Utilizing Concealed Nodoventricular or His-Ventricular Pathways: A Structured Approach to Diagnosis and
Satoshi Higuchi1, Aleksandr Voskoboinik1, Jeffrey J Goldberger2
1Division of Cardiology, University of California-San Francisco, San Francisco, California, USA.
Insights
Diagnosing arrhythmias involving concealed nodoventricular (cNV) or His-ventricular (cHV) pathways requires a structured approach. Electrophysiologic studies, including His-Purkinje system activation patterns and ventricular pacing, are crucial for identifying these challenging pathways.
Area of Science:
- Electrophysiology
- Cardiology
- Cardiac Electrophysiology
Background:
- Concealed nodoventricular (cNV) and His-ventricular (cHV) pathways can participate in tachyarrhythmias.
- Diagnosing these accessory pathways is often challenging due to their concealed nature.
Purpose of the Study:
- To describe the electrophysiologic characteristics of arrhythmias associated with cNV or cHV pathways.
- To outline diagnostic maneuvers for identifying cNV or cHV pathways.
- To present treatment strategies for these arrhythmias.
Main Methods:
- Case series presentation of four patients with tachycardias involving cNV or cHV pathways.
- Electrophysiologic study including His-Purkinje system activation mapping.
- Ventricular pacing maneuvers (entrainment, premature ventricular complexes).
- Radiofrequency ablation.
Main Results:
- Case 1: Narrow complex tachycardia with ventriculoatrial dissociation, suggestive of cNV pathway.
- Case 2: Nonsustained narrow complex tachycardia with His-right bundle (RB) activation and normal His-ventricular (HV) interval, suggesting cNV pathway.
- Cases 3 & 4: Wide complex tachycardias (WCT) with eccentric His-RB activation and short HV interval, suggesting cHV (fasciculoventricular) pathway involvement.
- Successful ablation at the proximal RB terminated tachycardia in one case.
Conclusions:
- A systematic diagnostic approach is essential for managing cNV and cHV pathways.
- Evaluating His-RB activation patterns and HV intervals during sinus rhythm and tachycardia is critical.
- Ventricular pacing studies aid in pathway identification and treatment planning.
Objectives:
This study sought to describe the electrophysiologic characteristics, diagnostic maneuvers, and treatment of a series of arrhythmias using concealed nodoventricular (cNV) or His-ventricular (cHV) pathways.
Background:
Confirming the presence and participation of cNV or cHV pathways in tachyarrhythmias is challenging.
Methods:
We present 4 cases of tachycardias with a participatory cNV or cHV pathway.
Results:
The first patient had a narrow complex tachycardia with ventriculoatrial dissociation. Findings of an entrainment pacing from the right ventricle and fused premature ventricular complexes suggested cNV pathway involvement. The second patient had nonsustained narrow complex tachycardia with more ventricular than atrial complexes. The tachycardia exhibited an anterograde His-right bundle (RB) activation sequence and normal His-ventricular (HV) interval and consistently terminated with fused ventricular extra stimuli, suggesting cNV pathway participation. The third patient had a wide complex tachycardia (WCT) with either a right or left bundle branch block pattern. The WCT showed an eccentric His-RB activation sequence and short HV interval and terminated with fused premature ventricular complexes, suggesting a cHV (or concealed fasciculoventricular) pathway involvement. The fourth patient had a WCT with alternating bundle branch block morphologies with a short HV interval. Entrainment from the basal right ventricle demonstrated fusion and a short postpacing interval, suggesting cHV (or fasciculoventricular) pathway involvement. Ablation at the proximal RB rendered the tachycardia noninducible.
Conclusions:
A structured approach can help diagnose and treat cNV or cHV pathways. We emphasize the importance of evaluating both the His-RB activation pattern and HV interval during sinus rhythm and tachycardia as well as the ventricular pacing study.
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