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Optimized mapping of slow pathway ablation guided by subthreshold stimulation: a randomized prospective study in patients with recurrent atrioventricular nodal re-entrant tachycardia

Stephan Willems, MD^*, Christian Weiss, MD^*, Mohammad Shenasa, MD, FACC, Rodolfo Ventura, MD^*, Matthias Hoffmann, MD^* and Thomas Meinertz, MD^*

^* Department of Cardiology, University Hospital Eppendorf, Hamburg, Germany
Department of Cardiovascular Services, O‘Connor Hospital, San Jose, California, USA

View larger version (25K): [in a new window]   Figure 1 Subthreshold stimulation (STS) during atrioventricular nodal re-entrant tachycardia at a posteroseptal mapping position. After induction of sustained atrioventricular nodal re-entrant tachycardia (cycle length: 395 ms), STS is applied for 5 s (see arrows). The tachycardia is interrupted due to selective block within the slow anterograde pathway after 1.5 s, and normal sinus rhythm is established. Please note that no apparent capture is visible at surface electrocardiogram or intracardiac recordings. The termination of the tachycardia is preceded by discrete prolongation of the cycle length from 395 to 430 ms. This is suggestive of the slowing of conduction within the slow pathway because the A-to-H interval, but not the H-to-A interval, is prolonged. CSdis = coronary sinus, distal; CSprox = coronary sinus, proximal; HBE = His bundle electrocardiogram; HRA = high right atrium; MAP = mapping catheter; RVA = right ventricular apex.

View larger version (21K): [in a new window]   Figure 2 Distribution of successful ablation sites. This Figure depicts all target sites with subsequent abolition of atrioventricular nodal re-entrant tachycardia in patients undergoing the conventional approach (group A, open circles) and STS-guided ablation strategy (group B, solid circles). There is a well-balanced distribution of target sites from the posteroseptal aspect around the coronary sinus ostium up to the lower midseptal region in both groups. Solid circle = STS, n = 50; open circle = conventional, n = 50. AVN = atrioventricular node; CS = coronary sinus; TA = tricuspid annulus.