Radiofrequency ablation therapy in concealed left free wall accessory pathway with decremental conduction

An electrophysiologic study followed by transcatheter radiofrequency ablation therapy was performed in two adult patients with a permanent form of junctional tachycardia. Both patients had no structural heart disease and exhibited a normal resting ECG. The P wave during tachycardia was negative in leads 1, 3, and aVF, biphasic over V6, and positive in V1 and aVL in both patients, while the P-R/R-P interval ratio during tachycardia was 0.82 and 0.36, respectively, in both patients. Both patients displayed an eccentric atrial activation sequence with the earliest atrial activation occurring at the distal coronary sinus and a decremental retrograde conduction property during incremental ventricular pacing, suggesting the presence of a concealed slowly conducting left free wall accessory pathway. The tachycardia used the normal atrioventricular pathway for anterograde conduction and the concealed show left accessory pathway for retrograde conduction. It was terminated following adenosine administration in both patients; termination of tachycardia was due to a block in the retrograde accessory pathway in one patient and due to a block in the atrioventricular node in the other patient. Radiofrequency ablation was performed by the retrograde transaortic approach. The radiofrequency f4p4ent was delivered to the site of the earliest atrial activation during tachycardia at the ventricular aspect of the mitral annulus. The successful ablation site had a ventriculoatrial (VA) interval of 120 and 130 ms, respectively, and was located at the posterolateral and lateral aspects of the mitral annulus. Following ablation, there was no VA conduction; however, conduction through the normal atrioventricular pathway was noted during isoproterenol infusion in both patients. There was no induction of tachycardia. This study demonstrates that the permanent form of junctional tachycardia in adults can incorporate a concealed left free wall accessory pathway with a decremental property. Radiofrequency ablation therapy is effective and safe in this form of arrhythmia.