Unusual Response of Concealed Left Accessory Pathway to Intavenous Adenosine Following Radiofrequency Catheter Ablation

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A 32 year old man presented with a history of paroxysmal palpitations. He did not have any structural heart disease. ECG during sinus rhythm showed no pre-excitation. Baseline intervals in sinus rhythm were normal. Right ventricular (RV) apical pacing at 500 ms revealed eccentric ventriculo-atrial (VA) conduction; the earliest atrial activation was seen in the distal coronary sinus (CS). Ventricular extra stimulation showed non-decremental conduction with the same atrial activation sequence. Sustained narrow-QRS tachycardia with 1:1 VA relationship was induced with PES of atria at 500:300:270 msec. The TCL was 280 msec. The CS activation sequence was from distal to proximal. A diagnosis of an orthodromic tachycardia via a left free wall accessory pathway was made and radiofrequency ablation was performed via the trans-septal approach. Three pulses were given at 3 o'clock mitral valve annular position during RV pacing at 500 msec. The activation pattern in CS became proximal to distal during the third RF delivery. Pacing at 500 msec from the LV confirmed the change in activation sequence. 12 mg of intravenous Adenosine was given during LV pacing at 500 msec and the result was intriguing. Ablation procedure was successfully completed following two more energy deliveries in the same region. Thereafter, repeat testing with intravenous adenosine resulted in transient VA block, all conducted beats showed activation from the proximal to the distal CS.
日本不整脈学会の論文

Unusual Response of Concealed Left Accessory Pathway to Intavenous Adenosine Following Radiofrequency Catheter Ablation

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