Conclusion
We described a case of adenosine-sensitive AT originating from the
para-Hisian region with a SCZ in the anteroseptal LA. The SCZ of the AT
circuit may be located in the LA even if the earliest atrial activation
is observed at the HBE among the electrodes initially placed. Even from
the LA, a manifest entrainment guided ablation strategy can be a
reasonable option to minimize the potential risk of AV block.
Figure 1
A: The twelve-lead electrocardiography revealed a long-RP, narrow QRS,
regular tachycardia with a heart rate of 132 beats/min. The P-wave
morphologies were positive in leads aVL and V1 and biphasic
(negative/positive) in leads II, III, and aVF. B: Ventricular burst
pacing during the sinus rhythm revealed ventriculoatrial (VA)
dissociation. C: The difference in the postpacing ventriculoatrial
interval between the high right atrium (HRA) and proximal coronary sinus
(CS) entrainment pacing was 44ms > 14ms, indicating the
absence of VA linking. D: A 4-mg bolus injection of
adenosine5-triphosphate (ATP) terminated the supraventricular
tachycardia without atrioventricular block. d = distal; HBE = His-bundle
electrode; RVA = right ventricular apex; p = proximal; S = stimulation.
Figure 2
A: Activation maps during the tachycardia. The earliest activation site
in the right atrium (EAS-RA), noncoronary aortic sinus (EAS-NCS), and
left atrium (EAS-LA) are indicated. The blue star (site A) shows the
pacing site where manifest entrainment was observed. The red tag (site
B) indicates the successful ablation site. B: The local atrial
electrograms of the EAS-RA, EAS-NCS, EAS-LA, site B, and site A during
the AT preceded that of the CS proximal electrode by 35 ms, 41 ms, 44
ms, 36 ms and 32 ms respectively. AP = anterior-posterior; PA =
posterior-anterior; SVC = superior vena cava; RA = right atrium; NCS =
noncoronary aortic snus; LA = left atrium; MVA = mitral valve annulus;
TVA = tricuspid valve annulus; MAP = mapping catheter. The other
abbreviations are as in Figure 1.
Figure 3
A: Entrainment pacing from site A. The cycle lengths of the tachycardia
and pacing are 455ms and 440ms respectively. The red arrows indicate the
orthodromic atrial activation, and the red asterisks indicate the last
orthodromic captured electrograms. The blue arrows indicate the
antidromic atrial activation, and the blue asterisks indicate the last
antidromic captured electrograms. B: Schematic representation of
manifest entrainment from site A. The antidromic wavefront (n) captures
the coronary sinus (CS), and the orthodromic wavefront of the previous
beat (n-1) exits from the slow conduction zone of the reentrant circuit
and captures the high right atrium (HRA) and His bundle electrode (HBE),
and propagates to the ventricle. C: Schematic representation of a reset
of the AT by a premature atrial complex (PAC). A PAC captures the AV
node before the tachycardia wavefront exited from the SCZ. AVN =
atrioventricular node; TV = tricuspid valve; MV = mitral valve. The
other abbreviations are as in the previous figures.
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