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Br J: first published as 10.1136/hrt.34.5.508 on 1 May 1972. Downloaded from British Heart journal, 1972, 34, 508-5 I2. Hazard of cardiac catheterization in patients with ventricular pre-excitation

C. Ward, K. G. Lowe, and Hamish Watson From the University Department of Cardiology, and the Royal Infirmary, Dundee

The scalar and intracardiac electrocardiograms recorded at the time of cardiac catheterization in 5 patients with ventricular pre-excitation have been analysed. Four patients had paroxysmal tachycardia on one or more occasions during the procedure. In each case where complete records were available the dysrhythmia was an atrial reciprocating tachycardia and this rhythm wasnoted at some time during each of thefourprocedures. Sinus rhythm could often be restored by stimulating the heart wall with the tip of the . Two out of three patients with no previous history of dysrhythmia developed tachycardia for thefirst time during cardiac catheterization.

Ventricular pre-excitation may be an innocent the bundle of His electrocardiogram, and to finding in patients with otherwise normal study the spread of excitation in the ventricles . However, paroxysmal tachycardia (Watson and Lowe, I967; Watson, Emslie- occurs spontaneously in about 70 per cent of Smith, and Lowe, I967; Castillo and Castil- cases (Wolff, I954; Chung, Walsh, and lanos, I970). Massie, I965) and the term Wolff-Parkinson- We have catheterized 5 patients with ven- White syndrome (Wolff, Parkinson, and tricular pre-excitation and suspected con- http://heart.bmj.com/ White, I930) may then be used correctly. genital heart disease or cardiomyopathy Paroxysmal tachycardia and an otherwise nor- (Table). Three had no history of paroxysmal mal heart were essential features of the syn- tachycardia; of these, 2 had Ebstein's anomaly drome described by Wolff, Parkinson, and and the other a small ventricular septal defect. White, and the term should therefore not be All 3 had type B (presumed right ventricular) used as an alternative name for ventricular pre-excitation. In the patient with a ventricu- pre-excitation when it is accompanied by lar septal defect the procedure was uneventful neither of these features. The paroxysmal and no tachycardia occurred. Paroxysmal on September 26, 2021 by guest. Protected copyright. tachycardia when it occurs is usually a rapid, tachycardia occurred during cardiac catheter- regular supraventricular tachycardia; much ization in both patients with Ebstein's less frequently it is atrial flutter or fibrillation anomaly. One (Case i) was catheterized in (Newman, Donoso, and Friedberg, I966). I953 and I959. On each occasion the proce- Although the majority of patients with ven- dure was abandoned because of prolonged tricular pre-excitation have otherwise normal supraventricular tachycardia unresponsive to hearts, it has a well-recognized association carotid sinus pressure, but eventually settling with congenital heart disease, especially Eb- spontaneously after several hours. At that stein's anomaly of the tricuspid valve, with time we were neither aware of the nature of cardiomyopathy, and with other cardiac dis- the dysrhythmia nor of the method of termin- orders. Such patients may have to undergo ating it. On the first occasion the onset of the diagnostic cardiac catheterization, and it may dysrhythmia was not recorded, but on the be anticipated that those with a history of second occasion it was. The dysrhythmia be- paroxysmal tachycardia will develop a dys- gan immediately after the compensatory rhythmia during the procedure. pause after a ventricular and was In those with ventricular pre-excitation and clearly a reciprocating atrial tachycardia. On heart disease requiring cardiac catheterization, the first occasion the catheter tip was in the the opportunity may be taken to determine right ; on the second it was in the the mechanism of the dysrhythmia, to record right . The other patient (Case 2) developed tachycardia during angiocardio- Received 23 August I971. graphy. The dysrhythmia followed an atrial Reciprocating tachycardia during catheterization in pre-excitation 509 Br Heart J: first published as 10.1136/hrt.34.5.508 on 1 May 1972. Downloaded from

TABLE Cardiac catheterization in patients with ventricular pre-excitation Case No. Age Scalar electrocardiogram Clinical diagnosis Dysrhythmia during cardiac and sex (yr) catheterization I, M I2 Type B pre-excitation and Ebstein's anomaly Atrial reciprocating tachycardia right bundle-branch block followed burst of ventricular ectopic beats in RV; QRS narrow 2, M 12 Type B pre-excitation Ebstein's anomaly Atrial reciprocating tachycardia followed atrial ectopic beat during angiocardiography; QRS narrow 3, M 5 Type B pre-excitation Small VSD (membranous No tachycardia septum repaired) 4, M i8 dy Type A pre-excitation Paroxysmal tachycardia Atrial reciprocating tachycardia provoked by atrial ectopic beat followed by long PR interval; QRS narrow 5, F 24 Type A pre-excitation Paroxysmal tachycardia, Atrial reciprocating tachycardia, cardiomyopathy recurrent paroxysms; QRS narrow

ectopic beat and again was a reciprocating the AV node and bundle of His accounts for atrial tachycardia. the narrow QRS with absence of the delta Two patients had type A (presumed left wave. This paroxysm was terminated during a ventricular) pre-excitation; one (Case 5) had burst of multifocal atrial ectopics as the cathe- , suspected cardiomyopathy having had an ter tip was pressed against the lateral wall of episode of unexplained left ventricular failure the right atrium. after a recent pregnancy and the other (Case 4) suspected congenital heart disease, not, however, confirmed at catheterization. Both Discussion

had a history of spontaneous paroxysmal Incidence of dysrhythmia in pre-excita- http://heart.bmj.com/ tachycardia. Case 4 developed reciprocating tion during diagnostic cardiac catheter- atrial tachycardia during cardiac catheteriza- ization Spontaneous dysrhythmia in pre- tion, after atrial ectopic beats when the cathe- excitation is most commonly said to be ter tip was in the right atrium. Case 5 had supraventricular tachycardia, less commonly recurrent attacks of reciprocating tachycardia atrial fibrillation and, least commonly, atrial during catheterization of both the right ven- flutter; the incidence being 8o, i6, and 4 per tricle and the right atrium; on each occasion cent, respectively (Newman et al., I966).

it was precipitated by atrial ectopic beats. In Sudden death is well known to occur in such on September 26, 2021 by guest. Protected copyright. both patients the dysrhythmia was easily ter- patients. The mechanism of this is not clear, minated by stimulating the atrial or ventricu- but it has been suggested that atrial fibrillation lar endocardium with the catheter tip to pro- may lead to ventricular fibrillation: rapid, 9 duce ectopic beats. repeated stimulation of the ventricle, prob- ably via the bypass fibres, resulting in occa- Mechanism of atrial tachycardia sional stimulation of the ventricle during the In each of our cases, as is usual, the QRS was vulnerable period (Rosenbaum, I970). How- narrowed during the tachycardia due to loss ever, ventricular pre-excitation has not been of the delta wave. In those paroxysms with commented on as a particular hazard during complete records, initiation and termination cardiac catheterization and seems to be in- * of tachycardia by atrial or ventricular ectopic frequently associated with serious dys- beats were noted and a typical recording is rhythmia in diagnostic procedures. The shown in the Figure. Co-operative Study on Cardiac Catheterization An atrial ectopic beat (Pe) is recognized by of the American Heart Association (Braun- its prematurity and by its aberrant form re- wald and Swan, i968) was a prospective study corded from the electrode on the tip of the of 12,367 diagnostic catheterizations over a catheter. After a prolonged Pe-R interval the two-year period. In this series, I49 patients & first QRS complex of the tachycardia is fol- experienced I53 major dysrhythmias. Of 59 lowed quickly by a P wave showing reversed cases of ventricular fibrillation, 23 occurred polarity (P'): the initial atrial activation of the during the 3,290 coronary arteriographies, 6 dysrhythmia. Antegrade conduction solely by of them in patients without heart disease, one SIO Ward, Lowe, and Watson Br Heart J: first published as 10.1136/hrt.34.5.508 on 1 May 1972. Downloaded from

LEAD 2 Pe IP1-

IEG

FIG. Lead II of the electrocardiogram and the intracardiac electrocardiogram (IEG) recorded from Case 4 during cardiac catheterization. Pe indicates atrial ectopic beat and P' indicates reciprocal atrial activation showing reversed polarity. For full description see text. of whom had Wolff-Parkinson-White syn- tion. Two of the other three developed tachy- drome. Supraventricular tachydysrhythmias cardia, one of them on two separate occasions. were surprisingly infrequent, possibly because minor episodes were disregarded for the pur- Nature of reciprocal atrial tachycardia http://heart.bmj.com/ poses of the study. Of the 35 cases recorded in Granted that a bypass mechanism accounts the whole series of I2,367 patients, 29 were in for ventricular pre-excitation, then a pathway the age group 6 to 6i years. Three of these 29 exists for re-entry of the excitation wave into patients had Wolff-Parkinson-White syn- the atrium. Antegrade conduction from atrium drome, i8 had congenital heart disease, and to ventricle may be by the normal pathway (AV 5 of the I8 had Ebstein's anomaly. It is not node and bundle of His) and re-entry by the reported whether any of the 3 cases of Wolff- bypass fibres or, less commonly, vice versa.

Parkinson-White syndrome had Ebstein's Such a reciprocal rhythm, the so-called atrial on September 26, 2021 by guest. Protected copyright. anomaly. Because Ebstein's anomaly is so or reversed reciprocating tachycardia, has commonly associated with ventricular pre- been recognized infrequently in patients with excitation and also because catheterization pre-excitation from recordings of spontaneous has in the past been considered especially episodes of tachycardia (Wolff, I954; Har- hazardous in patients with Ebstein's anomaly, nischfeger, I959; Schamroth, I960; Harris, it would be important to investigate this fur- Semler, and Griswold, I964; Kistin, I965; ther. Fortunately one of us (H.W.) has some McHenry, Knoebel, and Fisch, I966; Roe- data on this point. In a study of 406 patients landt and Van der Hauwaert, I968; Scham- with Ebstein's anomaly of the tricuspid valve, roth and Coskey, I969; Liuria and Hale, 303 underwent cardiac catheterization. Of 1970), though it may well be the usual these 303 diagnostic catheterizations, 53 were mechanism of the paroxysmal tachycardia. said to be complicated by paroxysmal supra- Unequal responsiveness or refractoriness of ventricular tachycardia. Eleven of these 53 two AV nodal pathways is essential, otherwise patients had ventricular pre-excitation and i the potential initiating impulse would traverse of them died from because the both pathways simultaneously, and reciprocal ventricular rate could not be controlled. activation of the atria would be impossible. Four of our 5 patients with pre-excitation The dysrhythmia is preceded by a prolonged had paroxysmal tachycardia during cardiac PR interval, a prolonged RP' interval, or catheterization. In the 2 with a history of both, producing a prolonged atrial reciprocal spontaneous dysrhythmia, frequent episodes time. (P' indicates retrograde atrial activation.) of tachycardia occurred during catheteriza- Whichever of these factors is present (pro- Reciprocating tachycardia during catheterization in pre-excitation 511 Br Heart J: first published as 10.1136/hrt.34.5.508 on 1 May 1972. Downloaded from

longed PR or prolonged RP') the result is the Castillo, C. A., and Castillanos, A. (1970). His bundle recordings in patients with reciprocating tachy- same; the atrium is sufficiently recovered to cardias and Wolff-Parkinson-White syndrome. respond to the reciprocal impulse. This ap- Circulation, 42, 27I. plies whether the initiating impulse is of atrial, Chung, K-Y., Walsh, T. J., and Massie, E. (I965). e nodal, or ventricular origin. Thus the dys- Wolff-Parkinson-White syndrome. American Heart 69, ii6. can be precipitated by sinus beats Journal, rhythmia Durrer, D., Schoo, L., Schuilenburg, R. M., and or by ectopic beats of atrial, nodal (AV junc- Wellens, H. J. J. (I967). The role of premature tional), or ventricular origin (Schamroth and beats in the initiation and the termination of supra- Yoshonis, I969). These authors have sug- ventricular tachycardia in the Wolff-Parkinson- gested that dual pathways may exist within White syndrome. Circulation, 36, 644. in some Giraud, G., Peuch, P., Latour, H., and Hertault, J. the AV node and function patients (I960). Variations de potentiel lies a l'activite du r with ventricular pre-excitation, the narrowed systeme de conduction auriculo-ventriculaire chez QRS and loss of delta wave during paroxys- l'homme (enregistrement electrocardiographiques mal tachycardia being explained by ventricu- endocavitaire). Archives des Maladies du Coeur et lar activation via the normal (non bypass) des Vaisseaux, 53, 757. Harnischfeger, W. W. (1959). Hereditary occurrence route. The mechanism of reciprocal rhythm of the pre-excitation (Wolff-Parkinson-White) syn- in patients with ventricular pre-excitation was drome with re-entry mechanism and concealed worked out by deductive reasoning, but recent conduction. Circulation, 19, 28. l experimental work involving atrial pacing Harris, W. E., Semler, H. J., and Griswold, H. E. et (I964). Reversed reciprocating paroxysmal tachy- (Durrer et al., I967; Lau al., I967) cardia controlled by guanethidine in a case of and His bundle recording (Giraud et al., Wolff-Parkinson-White syndrome. American Heart I960; Watson et al., i967; Scherlag et al., Journal, 67, 8I2. i969) has served to validate the work of Kistin, A. D. (I965). Atrial reciprocal rhythm. Circula- earlier investigators. The pathway of the tion, 32, 687. Lau, S. H., Stein, E., Kosowsky, B. D., Haft, J. I., reciprocating tachycardia has been mapped Lister, J. W., and Damato, A. N. (I967). Atrial by the use of His bundle recordings (Castillo pacing and atrioventricular conduction in anomal- and Castillanos, I970; Massumi, I970), and ous atrioventricular excitation (Wolff-Parkinson- termination of reciprocating tachycardia by White syndrome). American Journal of Cardiology, 19, 354. endocardial stimulation has been demon- Liuria, M. H., and Hale, C. G. (1970). Wolff-Parkin- strated (Massumi, Kistin, and Tawakkol, son-White syndrome in association with atrial

I967; Ryan et al., I968). Though critical tim- reciprocal rhythm and reciprocating tachycardia. http://heart.bmj.com/ ing is apparently essential for termination of British Heart Journal, 32, 134. Massumi, R. A. (1970). His bundle recordings in bi- the dysrhythmia by a single induced ectopic lateral bundle-branch block combined with Wolff- } beat, repeated stimulation either of the atrium Parkinson-White syndrome. Antegrade type II or the ventricle will often stop the paroxysm. (Mobitz) block and I: i retrograde conduction through the anomalous bundle. Circulation, 42,287. Conclusions Massumi, R. A., Kistin, A. D., and Tawakkol, A. A. (I967). Termination of reciprocating tachycardia Our studies have shown that dysrhythmia is by atrial stimulation. Circulation, 36, 637. k common during cardiac catheterization in McHenry, P. L., Knoebel, S. B., and Fisch, C. (I966). on September 26, 2021 by guest. Protected copyright. patients with ventricular pre-excitation. Using The Wolff-Parkinson-White (W-P-W) syndrome with supernormal conduction through the anomal- intracardiac and con- ous bypass. Circulation, 34, 734. tinuous tape recording throughout the pro- Newman, B. J., Donoso, E., and Friedberg, C. K. cedure, the nature of the dysrhythmia can (1966). in the Wolff-Parkinson-White now be recognized. In those cases where the syndrome. Progress in Cardiovascular Diseases, 9, I47. onset of the dysrhythmia was recorded, it was Roelandt, J., and Van der Hauwaert, L. G. (I968). ; clear that the rhythm was a reciprocating atrial Atrial reciprocal rhythm and reciprocating tachy- tachycardia. Sinus rhythm can often be re- cardia in Wolff-Parkinson-White syndrome. Circu- stored by stimulating the wall of the atrium lation, 38, 64. Rosenbaum, M. B. (1970). Panel discussion on Wolff- or the ventricle with the tip of the catheter to Parkinson-White syndrome. In Symposium on Car- induce ectopic beats. However, the dysrhyth- diac Arrhythmias. Ed. by E. Sandoe, E. Flensted- mia may be serious or even fatal. Jensen, and K. H. Olesen. AB Astra, Sodertalie, Our findings add support to the suggestion Sweden. that the of in Ryan, G. F., Easley, R. M., Zaroff, L. I., and Gold- usual mechanism dysrhythmia stein, S. (I968). Paradoxical use of a demand pace- patients with ventricular pre-excitation is an maker in treatment of supraventricular tachycardia atrial reciprocating tachycardia. due to the Wolff-Parkinson-White syndrome. Observation on termination of reciprocal rhythm. Circulation, 38, I037. References Schamroth, L. (I960). Reversed reciprocating paroxys- Braunwald, E., and Swan, H. J. C. (I968). Eds. mal tachycardia and its relationship to the Wolff- Co-operative Study on Cardiac Catheterization. The Parkinson-White syndrome. American Heart Jour- American Heart Association, New York. nal, 59, 506. 512 Ward, Lowe, and Watson Br Heart J: first published as 10.1136/hrt.34.5.508 on 1 May 1972. Downloaded from

Schamroth, L., and Coskey, R. L. (I969). Reciprocal Watson, H., and Lowe, K. G. (I967). Intracavity po- rhythm, the Wolff-Parkinson-White syndrome and tentials in type B ventricular pre-excitation. British unidirectional block. British Heart Journal, 31, 6I6. Heart Journal, 29, 505. Schamroth, L., and Yoshonis, K. F. (I969). Mechan- Wolff, L. (I954). Syndrome of short P-R interval with isms in reciprocal rhythm. American J7ournal of abnormal QRS complexes and paroxysmal tachy- Cardiology, 24, 224. cardia (W-P-W syndrome). Circulation, I0, 282. Scherlag, B. J., Lau, S. H., Helfant, R. H., Berkowitz, Wolff, L., Parkinson, J., and White, P. D. (I930). W. D., Stein, E., and Damato, A. N. (I969). Bundle-branch block with short P-R interval in Catheter technique for recorded His bundle healthy young people prone to paroxysmal tachy- activity in man. Circulation, 39, 13. cardia. American Heart_Journal, 5, 685. Watson, H., Emslie-Smith, D., and Lowe, K. G. (1967). The intracardiac electrocardiogram of Requests for reprints to Dr. Hamish Watson, human atrioventricular conducting tissue. American Department of Cardiology, The University, Heart Journal, 74, 66. Dundee, DDI 4HN. http://heart.bmj.com/

Corrigendum Parsons, C. G., Astley, R., Burrows, F. G. O., discovered at postmortem examination in a baby

and Singh, S. P. (I97I). Transposition of who was moribund from diffuse pulmonary on September 26, 2021 by guest. Protected copyright. great arteries. A study of 65 infants followed haemorrhage when catheterization was begun. for I to 4 years after . Two perforations occurred before the septostomy British Heart_Journal, 33, 725-731. was actually attempted. Blalock-Hanlon pro- cedures were performed in both children. One I regret that our summary of the paper by survived and the other died of complications re- Venables (1970) was incorrect. The relevant lated to the surgical procedures. A fourth per- passage in the Discussion, p. 729, should read as foration, of the left atrial appendage, was associ- follows. ated with manipulation of the balloon catheter in the left atrium after performance of septostomy. Venables (1970) describes his experiences with occurred but the infant was re- 26 infants in a little less than 3 years. At the end suscitated. Thoracotomy was not required, and of this study, I7 children survived. Of 7 early this infant is still alive. Four children of the deaths, one appeared due to inadequate mixing of ii followed for at least six months required a blood through the . Four atrial second septostomy. One child sustained a cerebral perforations were noted. One perforation was venous thrombosis.