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(Circulation. 1996;93:1690-1701.)
© 1996 American Heart Association, Inc.

Articles

Electrophysiological Mechanisms in Successful Radiofrequency Catheter Modification of Atrioventricular Junction for Patients With Medically Refractory Paroxysmal Atrial Fibrillation

Shih-Ann Chen, MD; Shih-Huang Lee, MD; Chern-En Chiang, MD; Chin-Tai Tai, MD; Tsu-Juey Wu, MD; Chen-Chuan Cheng, MD; Zu-Chi Wen, MD; Chuen-Wang Chiou, MD; Kwo-Chang Ueng, MD; Mau-Song Chang, MD

From the Division of Cardiology, Department of Medicine, National Yang-Ming University; School of Medicine, Veterans General Hospital-Taipei; and Shin-Kong Memorial Hospital (S.-H.L.), Taiwan, ROC.

Correspondence to Shih-Ann Chen, MD, Director of Electrophysiology, Division of Cardiology, Department of Medicine, Veterans General Hospital-Taipei, 201 Sec 2, Shih-Pai Rd, Taipei, Taiwan, ROC.

Background Mechanisms and changes of electrophysiological (EP) characteristics in successful radiofrequency (RF) modification of right midseptal and posteroseptal areas for controlling rapid ventricular response to atrial fibrillation (Af) are not clear.

Methods and Results We studied 50 patients with medically refractory paroxysmal Af. Group 1 consisted of 40 patients without dual atrioventricular (AV) node physiology with modification sites located in the mid/posteroseptal area. Of the 40 patients, 36 had successful modification (follow-up of 14±8 months), and 3 had AV block. Late follow-up electrophysiological study (98±10 days) showed pattern 1 (67%) with prolongation of AV node effective refractory period (ERP, 40 milliseconds) and Wenckebach block cycle length (WBCL, 40 milliseconds); pattern 2 (22%) with prolongation of AH interval (20 milliseconds), ERP, and WBCL; and pattern 3 (11%) without any change in AV node conduction parameter. Change in ventricular rate negatively correlated with change of WBCL in patterns 1 (r=-.691, P=.019) and 2 (r=-.90, P=.01). Group 2 consisted of 10 patients with dual AV node pathway; elimination of slow pathway property was performed. Late follow-up electrophysiological study (92±7 days) showed that change in ventricular rate negatively correlated with change in AV node ERP (r=-.926, P=.0001) and WBCL (r=-.969, P=.0001). Four patients without significant modification effect had success after RF energy was delivered to higher levels (follow-up, 15±7 months).

Conclusions RF modification of right mid/posteroseptal area is feasible in 92% of patients with paroxysmal Af. Mechanisms of successful modification might be elimination of posterior input and/or partial injury of the compact node. Furthermore, simple elimination of slow pathway might be inadequate for control of ventricular rate in patients with little difference in conduction properties between fast and slow pathways.

Key Words: atrioventricular node • fibrillation • atrium • mechanics • catheter ablation

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