ORIGINAL ARTICLE
Permanent form of junctional reciprocating tachycardia in adults: peculiar features and results of radiofrequency catheter ablation
Cardiovascular Department, Hôpital de La Tour 1 Avenue JD Maillard, CH-1217 Meyrin, Geneva Switzerland ; Herzzentrum Bad Krozingen Germany ; Centre Médico-chirurgical Parly II Le Chesnay France ; Service de Cardiologie, CHU Michallon Grenoble France ; Service de Cardiologie, Clinique Pasteur Toulouse France ; Department of Cardiology, Universitair Ziekenhuis Gent Belgium
Manuscript submitted 19 January 2005. Accepted after revision 21 August 2005.
Corresponding author. Tel: +41 22 782 97 78; fax: 41 22 785 18 63. E-mail address: zimmermann.family{at}bluewin.ch
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Abstract |
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Aim PJRT occurs predominantly in infants and children and is limited to small series in adults. The aim of this study was to describe the clinical presentation, electrophysiological characteristics, feasibility and safety of radiofrequency ablation, and the long-term prognosis in a large group of adult patients with the permanent form of junctional reciprocating tachycardia (PJRT).
Methods and results Forty-nine adult patients (22 male and 27 female; mean age 43±16) with a diagnosis of PJRT confirmed at electrophysiological study were included. Eight patients (16%) presented with tachycardia-induced cardiomyopathy (TIC). Ventricular rate was 146±30 bpm. The arrhythmia was permanent or incessant in 23/49 cases (47%) and paroxysmal in 26/49 (53%). A significant correlation was found between symptom duration and tachycardia rate (r2=0.12, P=0.01). The accessory pathway (AP) was located in the right posteroseptal region in 37 cases (76%) and in atypical sites in 12 cases (24%).Patients with the incessant or permanent form of PJRT had longer duration of symptoms, more frequently TIC and a slower tachycardia rate. Radiofrequency catheter ablation was initially successful in 46 cases (94%) without any serious complication. Long-term success rate was 100% (49/49 patients) in the absence of any antiarrhythmic drug treatment (mean follow-up 49±38 months). Regression of TIC was observed in all cases (8/8).
Conclusion PJRT in adults is often paroxysmal (53%), and the retrograde slowly conducting, decremental AP is not infrequently in a non-posteroseptal location. Radiofrequency catheter ablation is highly effective and should be considered as the treatment of first choice in adult patients with PJRT.
Key Words: Permanent junctional reciprocating tachycardia, Accessory pathway, Radiofrequency catheter ablation, PJRT
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Introduction |
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Permanent junctional reciprocating tachycardia (PJRT) is a rare form of nearly incessant supraventricular tachycardia occurring predominantly in infants and children and characterized by a long RP' interval and, in the typical form, by negative P-waves in leads II, III, and aVF on the surface ECG. During sinus rhythm, the surface ECG is normal, without manifest pre-excitation. PJRT is caused by an atrioventricular (AV) re-entry using the AV node as the antegrade limb and a slowly conducting accessory pathway (AP) as the retrograde limb.1
–3 The location of the AP is commonly right posteroseptal with an atrial insertion close to the ostium of the coronary sinus, but other locations have been reported.4–7 Chronic uncontrolled tachycardia has been reported to result in tachycardia-induced cardiomyopathy (TIC), which usually recovers with adequate ventricular rate control.8,9 As PJRT is most of the time refractory to drug therapy, radiofrequency catheter ablation of the AP has become the treatment of first choice.10–13 The aim of the present multicentre retrospective study, the largest so far published, is to describe the clinical presentation of PJRT in an adult population, with special interest focused on the characteristics of the AP, on the feasibility and safety of radiofrequency ablation, and on the long-term follow-up for arrhythmia recurrence and improvement in left ventricular systolic function.
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Methods |
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Patients (Table 1)
This retrospective study included 49 patients (27 female and 22 male) with a mean age of 43±16 (range 18–72 years), referred for radiofrequency catheter ablation in six electrophysiological referral centres. Because the aim of the present study was to focus on PJRT in an adult population, infants, children, and adolescents are excluded from analysis.
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The diagnosis of PJRT was based on typical surface ECG criteria (long RP' interval, RP' greater than P'R, 1:1 AV ratio, and inverted P' wave in leads II, III, and aVF during tachycardia) (Figure 1) and on specific electrophysiological characteristics [exclusion of an atrial tachycardia by demonstrating that single ventricular extrastimuli introduced during tachycardia can reproducibly terminate the tachycardia without activating the atria; exclusion of an atypical form of AV nodal re-entrant tachycardia (fast–slow or slow–slow) by demonstrating the ability to pre-excite the atria with single ventricular extrastimuli applied during tachycardia at a time when the His bundle is refractory]. Only electrophysiological criteria were used when the AP was not typically located in the right posteroseptal region.
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Electrophysiological testing and radiofrequency catheter ablation procedure
The procedure was performed in the fasting state under local anaesthesia with pre-medication with lorazepam (1–2.5 mg) in selected cases. All antiarrhythmic medications were discontinued at least 72 h before the procedure. Two to four multipolar electrode catheters (4F, 6F, or 7F) were inserted percutaneously through the femoral vein and positioned in the high right atrium, His bundle position, coronary sinus, and right ventricle. For left-sided APs, an additional 7F sheath was introduced into the femoral artery, and the ablation procedure was performed using a retrograde transaortic approach. The diagnostic electrophysiological study was performed using standard techniques (multichannel digital recorder; analysis at a paper speed of 100 or 200 mm/s, with filter settings of 0.5–1000 Hz for the surface ECG and 0.5–500 Hz for intracardiac recordings; stimulation using 1-ms-duration pulses at twice diastolic threshold). Mapping and radiofrequency catheter ablation were performed using a 7F quadripolar temperature-controlled electrode catheter with a 4-mm tip and a deflectable curve. Location of the AP was assessed by intracardiac mapping and successful ablation on the basis of the shortest VA interval during tachycardia. Accessory pathway locations were classified as right anteroseptal, para-Hisian, right lateral, mid-septal, right posterolateral, left posteroseptal, left posterolateral, left lateral, left anterolateral, and left anterior. Radiofrequency current was delivered from the tip on a 7F deflectable temperature-controlled ablation catheter with a standard 4-mm tip; the radiofrequency generator was set so as to achieve a temperature of 50–65°C and a power of 45–55 W. A 1000–3000 IU bolus of heparin was given intravenously after catheter placement, followed by 1000 IU/h thereafter. Atropine or isoprenaline was used in selected cases. On completion of the procedure, all catheters and sheaths were removed and manual compression was maintained to achieve complete haemostasis. All patients received aspirin 100 mg/day for 4 weeks after the procedure.
Follow-up
A clinical follow-up evaluation was performed by the attending physician 2–3 weeks after the procedure and then at 6-month intervals. Effectiveness of radiofrequency catheter ablation was established by history and 24-h Holter recording to exclude recurrences of PJRT; echocardiography was used to assess recovery of systolic left ventricular function.
Statistical analysis
Values are expressed as mean±1 SD and ±SEM when appropriate.Differences in continuous variables between groups were analysed using Student's unpaired t-test. Differences in categorical data were performed using 
2 analysis. Pearson's correlation and linear-regression analysis were performed between tachycardia cycle length and age, duration of symptoms, and AH intervals. A P-value less than 0.05 was considered statistically significant.
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Results |
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Patients characteristics (Table 1)
The mean age of the study population was 43±16 years with a range from 18 to 72 years. Eleven patients (22%) had an associated cardiovascular abnormality: dilated cardiomyopathy, presumed to be related to the rapid ventricular rate, was present in eight (14%), coronary artery disease in two (4%), and sick sinus syndrome in one (2%). Forty-five patients (92%) complained of palpitations and six of malaise or dizziness (12%), but none had experienced syncope. Symptoms have been present for a median of 10 years (mean 153±144 months, range 1–498 months). Ventricular rate during tachycardia was 146±30 bpm (range 100–240 bpm). No patient had manifest pre-excitation during sinus rhythm on the 12-lead resting ECG. In 23/49 cases (47%), the arrhythmia was permanent or incessant, but in 26/49 (53%), the arrhythmia was paroxysmal with prolonged periods of normal sinus rhythm. Twenty patients (41%) never received any specific antiarrhythmic treatment; in the remaining 29 patients, a mean of 1.9±1.3 drug trials were attempted without success (beta-blocker 24; verapamil 13; digoxin 7; Class Ic 9; amiodarone 4).
Electrophysiological characteristics (Table 1)
AV re-entrant tachycardia was inducible in all patients during electrophysiological study. The diagnosis of PJRT was confirmed in all cases on the basis of predefined criteria (Methods). The mean cycle length of the induced tachycardia was 407±89 ms. There was a significant correlation between symptom duration and tachycardia cycle length (r2=0.12, P=0.01) but not between tachycardia cycle length and age (r2=0.001, P=0.79) or tachycardia cycle length and AH interval (r2=0.02, P=0.29). During sinus rhythm, the mean AH interval was 81±22 ms, and the mean HV interval was 46±10 ms. Although difficult to assess properly in several patients because of immediate tachycardia induction, the effective refractory period of the retrogradely conducting AP was 293±42 ms. Manifest ventricular pre-excitation was never demonstrated either during sinus rhythm or during programmed stimulation. A typical right posteroseptal location of the AP was present in 37 cases (76%). In 12 cases (24%), the location of the decremental slow conducting AP was atypical: mid-septal in three (6%), left posteroseptal in three (6%), left posterolateral in two (4%), left lateral in one (2%), left anterolateral in one (2%), and left anterior in two (4%). In three cases (6%), multiple APs were present (right posteroseptal+left lateral in one; left anterior+left lateral in one; right posteroseptal+right mid-septal in one). In one patient, slow–slow AVNRT was also present, and in one patient, atrial flutter and atrial fibrillation were induced during the electrophysiological evaluation.
Patients with the incessant or permanent form of PJRT had a longer duration of symptoms, more frequently TIC, and a longer tachycardia cycle length, but AH interval was not statistically different between the two groups (Table 2).
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Patients with TIC showed no statistical difference when compared with patients without cardiomyopathy, but they tended to be older and to have a longer duration of symptoms (Table 3).
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Radiofrequency catheter ablation data
Mapping was performed using the shortest VA interval during tachycardia (Figure 2). Radiofrequency catheter ablation was initially successful in 46 cases (94%) with a mean of 7±7 radiofrequency current applications (range 1–32). The mean interval between radiofrequency current application and interruption of tachycardia was 4.1±3.8 s (Figure 3). The mean power delivered was 43±14 W, and the mean duration of radiofrequency current application was 70±25 s. The mean procedure duration was 137±63 min, and the mean fluoroscopy time was 28±21 min. Figure 4 shows the site of successful radiofrequency catheter ablation for each of the 49 patients included in this study. The three cases (6%) with initial failure (one right posteroseptal AP and two posteroseptal AP inside the coronary sinus) were successfully ablated during a second procedure. No serious complication was observed during the ablation procedure. Only one minor complication occurred (first degree AV block) without any clinical consequences.
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Follow-up data
The mean follow-up was 49±38 months. In four cases (8%), a recurrence of PJRT was observed during follow-up (mean delay between the ablation procedure and recurrence was 2.4±2.1 months) and these four patients were successfully re-ablated in a second procedure. The long-term success rate was 100% (49/49 patients) in the absence of any antiarrhythmic drug treatment. Regression of left ventricular systolic dysfunction was observed during follow-up in all cases (8/8).
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Discussion |
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Clinical aspects
Classically, the permanent form of PJRT occurs in children or in young adults and is characterized by an incessant (sometimes permanent) supraventricular tachycardia. However, PJRT may be diagnosed at any age and can sometimes express itself as a paroxysmal form of supraventricular tachycardia with a long RP interval.14
,15 The present data in an adult population confirm that retrograde slowly conducting, decremental APs can present at any age. In this series, the paroxysmal form of PJRT was more common than previously reported,14,15 and this difference may be due to different patient populations or to different diagnostic criteria (clinical vs. electrophysiological). In infants and children, PJRT is most often incessant or permanent as shown by Lindinger et al.16 Table 4 summarizes clinical and electrophysiological data of major series published on the subject. In the present series as in others,14–16 there was a huge variability in tachycardia cycle length (from 260 to 600 ms) and tachycardia rate was significantly higher in patients with the paroxysmal form of PJRT when compared with patients with incessant or permanent tachycardia despite comparable AH intervals during sinus rhythm. However, there was no correlation between tachycardia rate and the presence of TIC, although the number of patients with this type of complication was too small to draw definite conclusions. TIC was observed in only eight cases (16%), and this figure is in accordance with previous observations.14–16 This type of complication was more frequently observed in patients with the incessant/permanent form of PJRT than in patients with the paroxysmal form, and it appears that the duration of tachycardia more than the intrinsic rate is responsible for left ventricular dysfunction. The paroxysmal form of PJRT appears to be more frequent in adults when compared with children, and this feature may explain why the diagnosis of PJRT may remain unrecognized until adulthood.9 Regression of left ventricular dysfunction after successful elimination of the AP was the rule in this series as in others.9,14–18
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Electrophysiological data
In the vast majority of PJRT cases, the retrograde slowly conducting, decremental AP is located in the posteroseptal region,1
,3,12,14–16 and therefore, catheter ablation is usually performed using a right-sided approach.14 However, other locations of the AP have been described in 12–24% of cases,7,14–15 and according to Gaïta et al.,14 a non-posteroseptal location appears more frequently in patients with paroxysmal PJRT than in patients with incessant or permanent tachycardia. This observation was confirmed in the present study (27 vs. 22%), but the difference was not statistically significant. The AP in PJRT can be observed in almost every location from mid-septal to left anterior, even though most of the APs are located around or just within the ostium of the coronary sinus.5,6,14
Catheter ablation
In the present study as in others,14,15,17,18 radiofrequency catheter ablation proved to be safe and highly effective for obtaining a definitive cure in patients with PJRT whatever the location of the AP (Table 4). Recurrences are not rare (from 13 to 23% in the literature; 8% in the present series), but long-term success is usually obtained after a second ablation procedure and ranged from 92 to 100%. The higher recurrence rate in PJRT compared with what is observed in non-decremental APs may be explained by the long, tortuous course of the AP along the AV sulcus.3 The complication rate is low, but cautious application of radiofrequency current is mandatory when the AP is located above the ostium of the coronary sinus or in the mid-septal region, because the risk of second- or third-degree AV block is in the range of 5–7%. According to our data, we believe that radiofrequency catheter ablation should be considered as the treatment of first choice in adult patients with PJRT. The situation is quite different in infants and children, because antiarrhythmic drug treatment appears to be more effective in this age group and because the complication rate of radiofrequency catheter ablation is inversely related to body weight.16,19,20 Cryoablation, as recently reported by Gaïta et al.,21 could represent a safe alternative in children by reducing the risk of AV block.
Limitation of the study
This study is retrospective and observational, collecting data from six different institutions. However, great efforts have been made to fulfil criteria and to confirm the specific electrophysiological features of PJRT. The population is a selected one, all patients being referred for catheter ablation after unsuccessful pharmacological management.
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Conclusion |
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PJRT in adults may have various clinical presentations and is often paroxysmal (53%), and the retrograde slowly conducting, decremental AP is not infrequently in a non-posteroseptal location. This study confirms that radiofrequency catheter ablation should be considered as the treatment of first choice in adult patients with PJRT for the following reasons: catheter ablation is highly successful, the complication rate is low, and PJRT may lead to TIC, which is reversible.
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Footnotes |
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>for the RETAC (Réseau Européen pour le Traitement des Arythmies Cardiaques)
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References |
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