Circulation, Vol 90, 2820-2826, Copyright © 1994 by American Heart Association
JH Jentzer, R Goyal, BD Williamson, KC Man, M Niebauer, E Daoud, SA Strickberger, JD Hummel and F Morady
BACKGROUND: Junctional ectopy may occur during radiofrequency (RF) catheter
ablation of the slow pathway in patients with atrioventricular nodal
reentrant tachycardia (AVNRT). The purpose of the present study was to
characterize this junctional ectopy quantitatively. METHODS AND RESULTS:
The subjects of this study were 52 consecutive patients with AVNRT who
underwent slow pathway ablation and 5 additional patients included
retrospectively because they had developed high-degree atrioventricular
(AV) block during the procedure. A combined anatomic and electrogram
mapping approach was used for slow pathway ablation, and AVNRT was
successfully eliminated in all patients. In the group of 52 consecutive
patients, the incidence of junctional ectopy was significantly higher
during 52 effective applications of RF energy than during 366 ineffective
applications (100% versus 65%, P < .001). Compared with ineffective RF
energy applications, successful RF energy applications had a significantly
longer duration of individual bursts of junctional ectopy (7.1 +/- 7.1
versus 5.0 +/- 7.0 seconds [+/- SD], P < .05), a greater total number of
junctional beats during the applications (24 +/- 16 versus 15 +/- 8, P <
.01), and a greater total span of time during which junctional ectopy
occurred (19 +/- 15 versus 11 +/- 12 seconds, P < .01). Four of the 52
patients plus an additional 5 patients developed transient AV block lasting
34 +/- 37 seconds. In 1 of the 9 patients who had transient AV block,
third-degree AV nodal block requiring a permanent pacemaker recurred 2
weeks later. In each of the 9 patients who developed AV block, there was
ventriculoatrial (VA) block in association with junctional ectopy during
the RF energy application immediately preceding the AV block. Among 48
patients who did not develop AV block, 17 patients had at least one episode
of VA block during junctional ectopy. The positive predictive value of VA
block during junctional ectopy for the development of AV block was 19% in
the consecutive series of 52 patients. Among 31 patients who always had 1:1
VA conduction in association with junctional ectopy, 12 had poor VA
conduction in the baseline state, with a VA block cycle length of at least
500 milliseconds during ventricular pacing. CONCLUSIONS: In patients with
AVNRT undergoing slow pathway ablation, junctional ectopy during the
application of RF energy is a sensitive but nonspecific marker of
successful ablation. The bursts of junctional ectopy are significantly
longer at effective target sites than at ineffective sites. VA conduction
should be expected during the junctional ectopy that accompanies slow
pathway ablation, even when there is poor VA conduction during baseline
ventricular pacing. VA block during junctional ectopy is a harbinger of AV
block in patients undergoing RF ablation of the slow pathway. If energy
applications are discontinued as soon as VA block occurs, the risk of AV
block may be markedly reduced.
ARTICLES
Analysis of junctional ectopy during radiofrequency ablation of the slow pathway in patients with atrioventricular nodal reentrant tachycardia
Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor 48109-0022.
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