Circulation, Vol 78, 598-611, Copyright © 1988 by American Heart Association
WM Jackman, KJ Friday, JA Yeung-Lai-Wah, DM Fitzgerald, B Beck, AJ Bowman, P Stelzer, L Harrison and R Lazzara
The ability to record accessory atrioventricular (AV) pathway activation
consistently may be uniquely beneficial in improving pathway localization,
identifying anatomic relations, and providing insight into unusual
conduction properties. For the purpose of recording left AV accessory
pathway activation, an electrode catheter was specially designed for use in
the coronary sinus. The orthogonal catheter has three sets of four
electrodes spaced evenly around the circumference. Electrograms were
recorded at low gain (less than 1 cm/mV) between adjacent electrodes on the
same set (interelectrode distance, 1.5 mm, center to center). This provides
a recording dipole perpendicular to the atrioventricular groove to enhance
recording of accessory pathway activation while minimizing overlapping
atrial or ventricular potentials. The orthogonal electrode catheter was
used in the electrophysiological study of 48 consecutive patients with 59
left AV accessory pathways. The catheter could be advanced along the
coronary sinus beyond the site of earliest retrograde atrial activation in
49 of the 59 accessory pathways. Activation potentials were recorded from
45 of the 49 (92%) accessory pathways accessible to the catheter (5 of 5
anterior, 8 of 8 anterolateral, 15 of 16 lateral, 5 of 5 posterolateral, 5
of 5 posterior, and 7 of 10 posteroseptal). Accessory pathway potentials
were validated by dissociating them from both atrial and ventricular
activation by programmed-stimulation techniques. During surgery, accessory
pathway potentials were identified from orthogonal catheter electrodes in
the coronary sinus in 14 of 16 accessory pathways (12 patients). Epicardial
mapping confirmed the location of the accessory pathway, and direct
pressure over the orthogonal catheter electrode that recorded the accessory
pathway potential resulted in transient conduction block in nine of the 14
accessory pathways. Orthogonal electrode maps of the coronary sinus
identified an oblique course in 39 of 45 recorded accessory pathways.
Thirty-two of 38 left free-wall accessory pathways were oriented with
atrial insertion 4-30 mm (median, 14 mm) proximal (posterior) to the
ventricular insertion. In the remaining six free-wall accessory pathways,
the lateral excursion could not be determined because either only the
atrial end of the accessory pathway was recorded or activation of multiple
pathway fibers prevented tracking of individual strands. The seven recorded
posteroseptal pathways exhibited accessory pathway potentials throughout an
8-18-mm (median, 10 mm) length of the proximal coronary sinus, but fiber
orientation was difficult to determine.(ABSTRACT TRUNCATED AT 400 WORDS)
ARTICLES
New catheter technique for recording left free-wall accessory atrioventricular pathway activation. Identification of pathway fiber orientation
Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City 73190.
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