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Novel Approaches for the Diagnosis of Concealed Nodo-Ventricular and His-Ventricular Pathways
Satoshi Higuchi1,2, Edward P Gerstenfeld1, Henry H Hsia1
1Division of Cardiology, University of California San Francisco (S.H., E.P.G., H.H.H., C.X.W., M.M.S.).
Insights
Diagnosing concealed nodo-ventricular (cNV) and His-ventricular (cHV) pathways in tachyarrhythmias can be challenging. Novel pacing techniques and adenosine administration aid in identifying these complex arrhythmias.
Area of Science:
- Electrophysiology
- Cardiology
Background:
- Diagnosing concealed nodo-ventricular (cNV) and concealed His-ventricular (cHV) pathways in tachyarrhythmias presents diagnostic challenges.
- Novel observations are described to assist in the diagnosis of cNV and cHV pathways.
Purpose of the Study:
- To present novel diagnostic observations for concealed nodo-ventricular (cNV) and His-ventricular (cHV) pathway-mediated tachyarrhythmias.
- To highlight the utility of differential ventricular overdrive pacing, His refractory premature ventricular complexes, paradoxical atriohisian response, and adenosine in diagnosis.
Main Methods:
- Seven cases of cNV and cHV pathway-mediated arrhythmias were analyzed.
- Key diagnostic methods included differential ventricular overdrive pacing (VOD) from base vs. apex, His refractory premature ventricular complexes, assessment of atriohisian response during long RP tachycardia, and adenosine administration.
Main Results:
- Differential VOD helped localize ventricular connections and differentiate from AVNRT.
- His refractory premature ventricular complexes without atrial conduction excluded certain reentrant circuits and suggested bystander cNV pathway involvement.
- Paradoxical atriohisian shortening in long RP tachycardia indicated parallel atrial and AV nodal activation.
- Adenosine terminated tachycardias with retrograde block in cNV pathways but was ineffective in a cHV pathway.
Conclusions:
- Concealed nodo-ventricular (cNV) and His-ventricular (cHV) pathways can cause variable tachyarrhythmias.
- Differential VOD, His refractory premature ventricular complexes, paradoxical atriohisian response, and adenosine are crucial for diagnosing these pathways.
Background:
Confirming the presence and participation of concealed nodo-ventricular (cNV) or concealed His-ventricular (cHV) pathways in tachyarrhythmias is challenging. We describe novel observations to aid in diagnosing cNV or cHV pathways.
Methods:
We present 7 cases of cNV and cHV pathway-mediated arrhythmias and focus on several laboratory observations: (1) differential ventricular overdrive pacing (VOD) from the base versus apex, (2) response to His refractory premature ventricular complexes, (3) paradoxical atriohisian response (shorter atriohisian interval during tachycardia than that during sinus rhythm) in long RP tachycardia, and (4) the role of adenosine to aid in the diagnosis.
Results:
Three cases underwent differential VOD during tachycardia. All demonstrated a shorter postpacing interval minus tachycardia cycle length during basal pacing than apical pacing with one case exhibiting apical VOD results compatible with atrioventricular nodal reentrant tachycardia. Basal VOD was useful for localizing the ventricular connection in a case with cHV pathway. In 3 cases, His refractory premature ventricular complexes reset the tachycardia without conduction to the atrium, which excluded the involvement of an atrioventricular pathway or atrial tachycardia, or atrioventricular nodal reentrant tachycardia alone. One case had His refractory premature ventricular complexes followed by subsequent constant AA interval and then tachycardia termination, suggesting a bystander cNV pathway involvement. Two cNV pathway cases presented with long RP tachycardia had paradoxical atriohisian shortening of >15 ms, suggesting parallel activation of the atrium and the atrioventricular node. Adenosine terminated the tachycardia with retrograde block in 2 cases with cNV pathways but had no response on a cHV pathway.
Conclusions:
cNV and cHV pathways mediated tachyarrhythmias can present with variable clinical presentations. We emphasize the important role of differential VOD sites, His refractory premature ventricular complexes that reset or terminate the tachycardia without conduction to the atrium, paradoxical atriohisian response in long RP tachycardia, and the use of adenosine for diagnosing cNV and cHV pathways.
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