PMC4321640_01
Twelve-lead rest electrocardiogram showing positive QRS complexes (with upright P and T waves) in aVR, inversion of all complexes in lead I, and absent R wave progression in the chest leads (dominant S waves throughout).
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A 12-lead resting electrocardiogram (ECG) showed sinus rhythm at a rate of 64 bpm, a positive QRS complex in aVR, a positive P wave in aVR and a biphasic P wave in aVL, and a prominent R wave in V1 with undetermined horizontal axis (Figure 1).
Twelve-lead electrocardiogram showing supraventricular tachycardia with a regular, narrow QRS tachycardia at a rate of 170 bpm, during which the P wave was indiscernible, in a patient with dextroposition of the heart.
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The clinical tachycardia was a regular, narrow QRS tachycardia at a rate of 170 bpm, during which the P wave was indiscernible (Figure 2).
A lung window setting computed tomography scan.. Notes: The scan reveals nearly a complete absence of the right lung and the absent right pulmonary artery (arrow). The space around the atretic pulmonary artery is filled with fibro-fatty tissue with collaterals. The heart and mediastinum are shifted toward the right side.. Abbreviations: LA, left atrium; LV, left ventricle; RV, right ventricle.
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Computed tomography showed a complete absence of the right lung with dextroposition of the heart (Figure 3).
Fluoroscopic view in the 15  anteroposterior projection after contrast injection.. Abbreviations: IVC, inferior vena cava; RA, right atrium; RV, right ventricle.
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The right atrium and the right ventricle were imaged on left lateral and anteroposterior views by contrast injection through inferior vena cava to reveal the cardiac anatomy (Figure 4).
Intracardiac recording.. Notes: (A) Three surface electrocardiographic leads and intracardiac electrograms are shown at a paper speed of 100 mm/s. Premature atrial stimulation at a coupling interval of 310 ms during a basic pacing cycle length of 600 ms initiated the typical form of atrioventricular nodal reentrant tachycardia. VA interval is 45 ms. (B) Slow pathway electrogram is shown in intracardiac electrogram (arrow).. Abbreviations: A, atrial intracardiac electrogram; abl d, distal ablation electrode; abl p, proximal ablation electrode; hra d, high right atrium distal; hra p, high right atrium proximal; V, ventricular intracardiac electrogram.
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During the electrophysiological study, a narrow QRS tachycardia with a cycle length of 270 ms was reproducibly induced by atrial premature stimulation with an extrastimulus (Figure 5A). Then, slow pathway potentials were recorded (Figure 5B).
Fluoroscopic image with a modified anteroposterior projection showing an ablation catheter at the region of the slow pathway (Abl) and a quadripolar diagnostic catheter on the His bundle position (D).
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Fluoroscopic views of the catheters during the ablation and mapping of the coronary sinus ostium are shown in Figures 6 and 7.
Fluoroscopic image with a modified anteroposterior projection showing an ablation catheter at the region of the coronary sinus ostium (CS os) and a quadripolar diagnostic catheter on the right ventricular outflow tract (RVOT).
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Fluoroscopic views of the catheters during the ablation and mapping of the coronary sinus ostium are shown in Figures 6 and 7.
Intracardiac electrogram of junctional rhythm after radiofrequency ablation of the slow pathway.. Abbreviations: A, atrial intracardiac electrogram; abl d, distal ablation electrode; abl p, proximal ablation electrode; hra d, high right atrium distal; hra p, high right atrium proximal; V, ventricular intracardiac electrogram.
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The current was applied for 60 seconds after junctional tachycardia was observed during ablation (Figure 8). ventriculoatrial block was not revealed during radiofrequency application.