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Characteristics of Right-Sided Accessory Pathways Associated With Right Cardiac Veins
Yiwei Lai1,2, Mingyang Gao1,2, Qifan Li1,2
1Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, China (Y.L., M.G., Q.L., M.L., Q.G., L.H., C.J., S.L., X.G., S.Z., N.L., W.W., X.Z., C.S., R.T., D.L., C.M.).
Insights
This study identifies a rare type of accessory pathway (AP) linked to right cardiac veins (RCVs). These RCV-APs originate away from the heart
Area of Science:
- Cardiology
- Electrophysiology
- Cardiac Anatomy
Background:
- The anatomical relationship between myocardial fibers surrounding right cardiac veins (RCVs) and accessory pathways (APs) is not well-documented.
- Understanding these connections is crucial for diagnosing and treating certain cardiac arrhythmias.
Purpose of the Study:
- To investigate the anatomical characteristics and electrophysiological role of accessory pathways associated with right cardiac veins (RCVs).
- To correlate electrocardiogram (ECG) findings with venographic patterns in patients with RCV-associated accessory pathways (RCV-APs).
Main Methods:
- Retrospective analysis of 566 patients with right-sided APs, identifying six cases of RCV-APs.
- Utilized the CARTO 3 system for mapping retrograde atrial activation during tachycardia or pacing.
- Acquired venography of RCVs at the earliest retrograde atrial activation site.
Main Results:
- Six RCV-APs were identified in patients with a median age of 30 years.
- Venography revealed three distinct patterns (Type I, II, III) based on RCV ventricular branches.
- ECG characteristics, including QRS and delta wave patterns, varied across venographic types.
- Earliest retrograde atrial activation occurred distant from the tricuspid annulus (median 16.75 mm).
- Successful ablation at the vein ostium eliminated AP conduction in all treated patients, with no recurrence during follow-up.
Conclusions:
- Right cardiac vein-accessory pathways (RCV-APs) represent a rare entity in right-sided APs.
- These pathways exhibit atrial insertions remote from the tricuspid annulus.
- ECG findings can suggest the ventricular insertion sites of RCVs in these rare APs.
Background:
The anatomy of myocardial fibers around the right cardiac veins (RCVs) and their roles in accessory pathways (APs) are rarely reported.
Methods:
Six RCV-APs were identified from 566 patients with right-sided APs. Mapping of retrograde atrial activation was performed using CARTO 3 system under orthodromic tachycardia or right ventricular pacing. Venography of RCVs was acquired at the earliest retrograde atrial activation.
Results:
Patients enrolled had a median age of 30 (11-51) years, 5 of them were male. Venography of RCVs could be classified into 3 distinct patterns based on the identified ventricular branches, right marginal vein only (type I; n=3), both right marginal vein and anterior cardiac veins (type II; n=2), and anterior cardiac vein only (type III; n=1). Patients with type I venography had rS QRS pattern in lead V1, negative delta wave in lead III and negative or isoelectric delta wave in lead aVF. However, patients with type II and III venography had QS QRS patterns in lead V1 and variable patterns of delta wave in inferior leads. Earliest retrograde atrial activation was found at a median of 16.75 (14.60-20.00) mm away from the tricuspid annulus, all with A larger than V. At the earliest retrograde atrial activation, far-field ventricular electrogram was found 30 ms later than QRS onset in 1 patient under sinus rhythm. AP conduction was eliminated by mechanical pressure in 2 and by radiofrequency ablation in 4 at the ostium of the veins colocalizing with the earliest retrograde activation of the right atrium. No recurrence was observed during 36 (10-60) months follow-up.
Conclusions:
The RCV-AP is a rare form of right-sided APs characterized by atrial insertions distant from the annulus. ECG-speculated ventricular insertion sites conformed to the location of identified RCVs.
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