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1/150. AV reentrant and idiopathic ventricular double tachycardias: complicated interactions between two tachycardias.

    An electrophysiological study was performed in a 61 year old man with Wolff- Parkinson-White (WPW) syndrome. At baseline, neither ventricular nor supraventricular tachycardias could be induced. During isoprenaline infusion, ventricular tachycardia originating from the right ventricular outflow tract (RVOT) with a cycle length of 280 ms was induced and subsequently atrioventricular reentrant tachycardia (AVRT) with a cycle length of 300 ms using an accessory pathway in the left free wall appeared. During these tachycardias, AVRT was entrained by ventricular tachycardia. The earliest ventricular activation site during the ventricular tachycardia was determined to be the RVOT site and a radiofrequency current at 30 W successfully ablated the ventricular tachycardia at this site. The left free wall accessory pathway was also successfully ablated during right ventricular pacing. The coexistence of WPW syndrome and cathecolamine sensitive ventricular tachycardia originating from the RVOT has rarely been reported. Furthermore, the tachycardias were triggered by previous tachycardias.
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2/150. Right coronary artery occlusion as a complication of accessory pathway ablation in a 12-year-old treated with stenting.

    We describe a complication of radiofrequency ablation of a posteroseptal pathway that resulted in acute occlusion of a distal right coronary artery in a pediatric patient. The complication was treated with coronary stenting after unsuccessful angioplasty.
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3/150. Radiofrequency ablation of a concealed nodoventricular Mahaim fiber guided by a discrete potential.

    INTRODUCTION: We present the case of a 17-year-old woman who underwent an electrophysiological study and radiofrequency (RF) ablation of supraventricular tachycardia refractory to medical treatment. Two right-sided, concealed, nondecremental atrioventricular accessory pathways (AV-APs) involved in orthodromic circus movement tachycardias were identified. After RF ablation of both AV-APs, evidence of bidirectional dual AV nodal conduction was demonstrated and regular narrow complex tachycardia was induced. methods AND RESULTS: During the tachycardia, retrograde slow and fast AV nodal pathway conduction with second-degree ventriculoatrial (VA) block and VA dissociation were observed. During the tachycardia with second-degree VA block, ventricular extrastimuli elicited during His-bundle refractoriness advanced the next His potential or terminated the tachycardia. Mapping the right atrial mid-septal region, a distinct high-frequency activation P potential was recorded in a discrete area, two thirds of the way from the His bundle toward the os of the coronary sinus. Detailed electrophysiologic testing with the recordable P potential demonstrated that the tachycardia utilized a concealed nodoventricular AP arising from the proximal slow AV nodal pathway. CONCLUSION: The tachycardia with slow 1:1 VA conduction could be reset by ventricular extrastimuli elicited during His-bundle refractoriness advancing the subsequent activation P potential and atrial activation. RF ablation guided by recording of the activation P potential resulted in elimination of both the slow AV nodal pathway and the nodoventricular connection with preservation of the normal AV conduction system.
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4/150. The ECG "lead I sign" in cardiac disease--an indicator of coexisting obstructive pulmonary disease.

    Two patients with co-existing cardiac disease and chronic obstructive pulmonary disease are described. The first patient had wolff-parkinson-white syndrome and the second patient had extensive anterior Q wave myocardial infarction. In addition to the distinctive ECG patterns of their cardiac abnormalities, both patients also showed the "lead I sign" which is a highly specific marker of chronic obstructive pulmonary disease. These two patients suggest that even in the presence of cardiac disease, the diagnosis of chronic obstructive pulmonary disease should be strongly suspected when the "lead I sign" is present.
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5/150. electrocardiography in the patient with the wolff-parkinson-white syndrome: diagnostic and initial therapeutic issues.

    The wolff-parkinson-white syndrome (WPW), estimated to occur in approximately 0.1% to 3% of the general population, is a form of ventricular preexcitation involving an accessory conduction pathway. The definition of WPW relies on the following electrocardiographic features: (1) a PR interval less than 0.12 seconds (2) with a slurring of the initial segment of the QRS complex, known as a delta wave, (3) a QRS complex widening with a total duration greater than 0.12 seconds, and (4) secondary repolarization changes reflected in ST segment-T wave changes that are generally directed opposite (discordant) to the major delta wave and QRS complex changes. The accessory pathway bypasses the atrioventricular (AV) node, creating a direct electrical connection between the atria and ventricles. The majority of patients with preexcitation syndromes remain asymptomatic throughout their lives. When symptoms do occur they are usually secondary to tachyarrhythmias; the importance of recognizing this syndrome is that these patients may be at risk to develop a variety of supraventricular tachyarrhythmias which cause disabling symptoms and, in the extreme, sudden cardiac death. The tachyarrhythmias encountered in the WPW patient include paroxysmal supraventricular tachycardia (both the narrow QRS and wide QRS complex varieties), atrial fibrillation, atrial flutter, and ventricular fibrillation. Diagnostic and urgent, initial therapeutic issues based on initial electrocardiographic information are presented via 5 illustrative cases.
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6/150. Transcatheter coil embolization of large-size patent ductus arteriosus in adult patients: usefulness and problems.

    Transcatheter coil embolization of the patent ductus arteriosus (PDA) has been frequently used in children, especially for small lesions. It was attempted in 3 adults using Cook detachable coils. For 2 of the patients, relatively old age and heart failure were the reasons for choosing coil embolization of the PDA. In the remaining patient, who had wolff-parkinson-white syndrome, coil embolization was performed after radiofrequency catheter ablation of Kent's bundle. Their respective minimal PDA diameters were 5.0 mm, 4.5 mm and 4.0 mm measured by transesophageal echocardiography. Two coils were placed in 2 patients and 1 coil in the remaining patient. After the procedures, the size of the left ventricle decreased and heart failure was improved in 2 patients, although all 3 patients had a residual shunt, which caused hemolytic anemia in 2 patients. Repeat coil-embolization procedures resulted in complete occlusion and the hemolysis disappeared in these patients. In adult patients who have heart failure due to large PDA, coil embolization with detachable coils, even if residual shunt persists, is useful for improvement of the heart failure. In cases of hemolysis related to residual shunt, a second coil-embolization procedure can improve it completely.
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7/150. Radiofrequency ablation of a posteroseptal atrioventricular accessory pathway in a left-sided tricuspid ring with Ebsteinlike anomaly in a patient with congenitally corrected transposition of the great arteries.

    Radiofrequency ablation successfully eliminated a posteroseptal accessory pathway in a left-sided tricuspid ring with Ebsteinlike anomaly in a patient with a congenitally corrected transposition of the great arteries.
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8/150. Marked anterograde decremental conduction over a rapidly conducting accessory pathway after radiofrequency ablation.

    We report on a patient with the wolff-parkinson-white syndrome who temporarily exhibited a marked anterograde decremental conduction over a rapidly conducting accessory atrioventricular pathway after successful radiofrequency ablation. By recording the intracardiac electrogram via the ablation catheter placed at the successful ablation site, we were able to exclude the possibility of the occurrence of anterograde decremental conduction in the atrial or ventricular myocardium between the accessory pathway and the recording electrodes.
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9/150. Demonstration of phase-3 and phase-4 retrograde block in a second concealed accessory pathway after an initial successful radiofrequency ablation of a 'normal' concealed accessory pathway.

    We report a patient with concealed wolff-parkinson-white syndrome who, following catheter ablation, demonstrated phase-3 and phase-4 retrograde block in a concealed accessory pathway. After an initial 'apparently successful' ablation, retrograde conduction was through the atrioventricular node during constant ventricular pacing. Ventricular extrastimulus testing was performed at a basic drive cycle length of 600 ms. Unexpectedly, ventricular extrastimuli at coupling intervals of 440-380 ms were conducted retrogradely over an accessory pathway, consistent with a phase-3 and phase-4 retrograde block in the accessory pathway. Residual accessory pathway conduction was eliminated in a single ablation session.
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10/150. Transient appearance of antegrade conduction via an AV accessory pathway caused by atrial fibrillation in a patient with intermittent wolff-parkinson-white syndrome.

    A 55 year old man with intermittent Wolff-Parkinson-White (WPW) syndrome had an episode of atrial fibrillation (AF) that lasted for 117 days. After interruption of the AF a Delta wave appeared that lasted for two days and then disappeared. exercise stress and isoprenaline infusion could not reproduce the Delta wave, but after another episode of AF which lasted for seven days a persistent Delta wave appeared that lasted for six hours. In an electrophysiological study performed on a day without a Delta wave, neither antegrade nor retrograde conduction via an accessory pathway was seen, but after atrial burst pacing (at 250 ms cycle length) for 10 minutes, a Delta wave appeared lasting for 16 seconds. Atrial electrical remodelling-that is, the shortening of the atrial effective refractory period caused by AF, is a possible mechanism of the appearance of the Delta wave.
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