Incessant atrioventricular tachycardia in an infant with postero-septal accessory pathway and coronary sinus diverticulum

  • Dr Artur Baszko, Pediatric Electrophysiology Laboratory and Department of Cardiology, University of Medical Sciences, Poland
  • Prof Waldemar Bobkowski, Department of Pediatric Cardiology, University of Medical Sciences, Poland
  • Dr Malgorzata Pawelec-Wojtalik, Department of Pediatric Cardiology, University of Medical Sciences, Poland
  • Dr Krzysztof Czyz, Department of Pediatric Cardiology, University of Medical Sciences, Portugal
  • Dr Alicja Bartkowska-Sniatkowska, Department of Pediatric Anesthesiology and Intensive Theraphy, University of Medical Sciences, Poland
  • Prof Aldona Siwinska, Department of Pediatric Cardiology, University of Medical Sciences, Poland
  • Prof Stefan Grajek, Poland

    • RF ablation of WPW syndrome is not recommended treatment for infants and small children, but cases of incessant tachycardia. The procedure can be further complicated by the presence of anatomical abnormalities, like diverticulum of the coronary sinus.
    We present an infant 1 month old with WPW syndrome and incessant orthodromic tachycardia who was unsuccessfully treated with amiodarone, flecainide, propranalol and digoxine. After intensive treatment including deep sedation, intubation and ventilation the tachycardia slowed down from 330 to 260/min., however the signs of heart failure were still present.
    The ablation was performed with 5F diagnostic and ablation (Marinr, 5F) electrodes. The ECG suggested left posteroseptal pathway (AP). This region was mapped through PFO, but local potentials were later in comparison to right sided location. We performed 2 applications in RPS region resulting in interruption of AP conduction and noninducibility of AVRT. However, the tachycardia recurred after the child returned to the ward, but without signs of preexcitation. The next day the procedure was repeated, starting with CS angiography which showed diverticulum. Retrograde AP conduction was abolished by compression with catheter. 90 minutes later, the retrograde AP conduction recurred and AVRT was induced. The CS and diverticulum were explored and two RF applications resulted in cessation of AP conduction. The follow-up of the child was uneventful, despite frequent atrial premature beats.
    The AP in posterosptal region can be associated with large diverticulum which may impede ECG interpretation. The save and successful ablation can be performed after angiographic visualization of the diverticulum.