PMC4119906_01
(a) Regular sinus rhythm at 70 beats per minute, a wide QRS and PR interval was 120 ms (b) post ablation we show a normal QRS.
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fig1
The ECG showed a regular sinus rhythm at 70 beats per minute, a complete right branch block, and posterior left hemiblock (Figure 1), and PR interval was 120 ms.
In atrial pacing, effective accessory pathway refractory period was 290 ms effective ((a) and (b)). The QRS had the same morphology during atrial pacing (c).
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fig2
Programmed atrial stimulation was performed in the basal state and showed an effective atrial refractory period of right atrium at 200 ms and effective refractory period of accessory tract was 300 ms (Figure 2).
The electrophysiology study showed a shorter AV at the distal electrode of decapolar (a) with dissociation atrioventricular conduction in retrograde (b). This figure confirmed the diagnosis of a left accessory bypass with only anterograde conduction.
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fig3
We inserted a catheter of exploration in coronary sinus; we recorded a shorter AV at the distal electrode of decapolar that confirmed the diagnosis of a left accessory bypass (Figure 3).
ECG after using isuprel: the use of isuprel showed the classic figure of Wolff-Parkinson-White syndrome with a typical QRS with slurred initial QRS.
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fig4
AV node (Figure 4). AH interval with isuprel was 100 ms and HV interval was 42 ms.
After the use of isuprel ((b) HV was 42 ms), HV interval was longer than the basal state ((a) HV was -24 ms). The isuprel accelerated atrioventricular conduction.
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fig5
This was explicated by an accelerated atrioventricular conduction with isuprel in addition to accessory pathway (Figure 5).
In atrial pacing, effective accessory pathway refractory period was 290 ms effective ((a) and (b)). The QRS had the same morphology during atrial pacing.
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fig6
The effective refractory period of accessory pathway was 210 ms with isuprel (Figure 6).
(a) Electrophysiology signal before the ablation. (b) The distal coronary sinus signal showed a separated ventricular signal from atria signal during ablation. The successful left accessory bypass ablation persisted.
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fig7
Thus, we had decided to ablate the accessory pathway (Figure 7).