Cryosurgical Ablation of the Atrioventricular Node‐His Bundle: Long‐term Follow‐up and Properties of the Junctional Pacemaker

We used a cryosurgical technique to ablate the atrioventricular (AV) node-His bundle in twenty-two selected patients with disabling supraventricular tachyarrhythmias unresponsive to medical management. Successful AV block was achieved in seventeen. There was no intraoperative mortality and significant surgical complications were not encountered. Electrophysiologic studies performed 7-10 days after surgery revealed that the subsidiary pacemaker had a narrow QRS complex morphology and a mean cycle length of 1244 msec. Isoproterenol (1-4 microgram/min i.v.) significantly increased (p less than 0.01) the rate of the subsidiary pacemaker (mean maximum response 1008.3 msec); atropine (2 mg i.v.) had no effect on its rate. The cycle length of the subsidiary pacemaker during long-term follow-up (mean 14.8 months) showed a small but significant (p = 0.024) increase (mean cycle length 1430 msec). Treadmill exercise in seven patients did not result in the subsidiary pacemaker exceeding the rate of the implanted demand pacemaker set at 70 beats/min. The properties of the subsidiary pacemaker suggest an intra-Hisian site of impulse formation.

[1]  V F Froelicher,et al.  The Initial Chest X‐ray in Acute Myocardial Infarction Prediction of Early and Late Mortality and Survival , 1980, Circulation.

[2]  P. Cohn.  Editorial: Evaluation of Inotropic Contractile Reserve in Ischemic Heart Disease Using Postextrasystolic Potentiation , 1980, Circulation.

[3]  R. Miller,et al.  Echo‐phonocardiographic Determination of Left Atrial and Left Ventricular Filling Pressures with and Without Mitral Stenosis , 1980, Circulation.

[4]  R. Herfkens,et al.  Detection of Patent Coronary Bypass Grafts by Computed Tomography: A Preliminary Report , 1980, Circulation.

[5]  S. Bharati,et al.  The Surgical Anatomy of Common Atrioventricular Orifice Associated with Tetralogy of Fallot, Double Outlet Right Ventricle and Complete Regular Transposition , 1980, Circulation.

[6]  D. Scherf,et al.  The atrioventricular node and selected cardiac arrhythmias , 1964 .

[7]  B. Holman,et al.  Disruption in the Temporal Sequence of Regional Ventricular Contraction: I. Characteristics and Incidence in Coronary Artery Disease , 1980, Circulation.

[8]  P. Cohn,et al.  Clinical Profile of Restrictive Cardiomyopathy , 1980, Circulation.

[9]  E. Lichstein,et al.  Electrophysiological features of complete AV block within the His bundle. , 1973, British heart journal.

[10]  L. T. Sheffield,et al.  Detection of Residual Jeopardized Myocardium 3 Weeks After Myocardial Infarction by Exercise Testing with Thallium‐201 Myocardial Scintigraphy , 1980, Circulation.

[11]  A. M. Lefer,et al.  Thromboxane Release During Pacing-induced Angina Pectoris: Possible Vasoconstrictor Influence on the Coronary Vasculature , 1980, Circulation.

[12]  M. Akhtar,et al.  Site of Conduction Delay During Functional Block in the His-Purkinje System in Man , 1980, Circulation.

[13]  S. King,et al.  Disabling Supraventricular Tachycardia of Wolff‐Parkinson‐White Syndrome (Type A) Controlled by Surgical A‐V Block and a Demand Pacemaker after Epicardial Mapping Studies , 1972, Circulation.

[14]  J. Talmon,et al.  Clinical Significance of Upsloping ST Segments in Exercise Electrocardiography , 1980, Circulation.

[15]  Robert H. Anderson,et al.  Morphology of the Human Atrioventricular Junctional Area , 1978 .

[16]  W. Boden,et al.  Postextrasystolic Potentiation of Regional Mechanical Performance During Prolonged Myocardial Ischemia in the Dog , 1980, Circulation.

[17]  N. Silverman,et al.  Evaluation of Pulmonary Hypertension by M-mode Echocardiography in Children with Ventricular Septal Defect , 1980, Circulation.

[18]  J. Gallagher,et al.  Wolff-Parkinson-White syndrome. The problem, evaluation, and surgical correction. , 1975, Circulation.

[19]  D. Kelly,et al.  Exercise‐induced ST‐segment Elevation: Correlation of Thallium‐201 Myocardial Perfusion Scanning and Coronary Arteriography , 1980, Circulation.

[20]  J. Pruett,et al.  Technique for experimental complete heart block. , 1967, Journal of applied physiology.

[21]  D. Zipes,et al.  New antiarrhythmic agents: amiodarone, aprindine, disopyramide, ethmozin, mexiletine, tocainide, verapamil. , 1978, The American journal of cardiology.

[22]  S. Chierchia,et al.  Sequence of Events in Angina at Rest: Primary Reduction in Coronary Flow , 1980, Circulation.

[23]  J J Gallagher,et al.  Cryosurgical Ablation of the A‐V Node‐His Bundle: A New Method for Producing A‐V Block , 1977, Circulation.

[24]  W. Kannel,et al.  Perspectives on Systolic Hypertension: The Framingham Study , 1980, Circulation.

[25]  B. Katzung,et al.  Test of a Model of Antiarrhythmic Drug Action Effects of Quinidine and Lidocaine on Myocardial Conduction , 1980, Circulation.

[26]  J. Kjekshus,et al.  The Relationship Between Cerebrospinal Fluid Creatine Kinase and Morphologic Changes in the Brain After Transient Cardiac Arrest , 1980, Circulation.

[27]  Thomas L. Crews,et al.  Surgically Induced Atrioventricular Block as Treatment for Recurrent Atrial Tachycardia in Wolff‐Parkinson‐White Syndrome , 1969, Circulation.

[28]  S. Ayres,et al.  Therapeutic surgical division of the human conduction system. , 1967, JAMA.

[29]  M. Dewood,et al.  Intraaortic Balloon Counterpulsation With and Without Reperfusion for Myocardial Infarction Shock , 1980, Circulation.

[30]  L. Horowitz,et al.  Epicardial and Endocardial Activation During Sustained Ventricular Tachycardia in Man , 1980, Circulation.

[31]  M. Welch,et al.  Scintigraphic Detection of Carotid Atherosclerosis with Indium‐111‐labeled Autologous Platelets , 1980, Circulation.

[32]  R. Lewis,et al.  Myocardial Perfusion as an Indicator of Graft Patency after Coronary Artery Bypass Surgery , 1980, Circulation.

[33]  E. Michelson,et al.  Spontaneous Variability of Complex Ventricular Arrhythmias Detected by Long‐term Electrocardiographic Recording , 1980, Circulation.

[34]  K. Fox,et al.  Hypoplastic and fibrotic sinus node associated with intractable tachycardia in a neonate. , 1980, Circulation.

[35]  B. Scherlag,et al.  Analysis of the A‐V Conduction Defect in Complete Heart Block Utilizing His Bundle Electrograms , 1970, Circulation.

[36]  F. Loop,et al.  Isolated Left Anterior Descending Coronary Atherosclerosis: Long‐term Comparison of Internal Mammary Artery and Venous Autografts , 1980, Circulation.

[37]  F. Bowman,et al.  Methods for Recording Electrograms of the Sinoatrial Node During Cardiac Surgery in Man , 1980, Circulation.

[38]  K. Rosen,et al.  Sites of Congenital and Surgical Heart Block as Defined by His Bundle Electrocardiography , 1971, Circulation.

[39]  C. Kawai,et al.  Echocardiographic Evaluation of Long‐term Effects of Exercise on Left Ventricular Hypertrophy and Function in Professional Bicyclists , 1980, Circulation.

[40]  K. Rosen,et al.  Localization of site of traumatic heart block with His bundle recordings: electrophysiologic observations regarding the nature of "split" H potentials. , 1972, The American journal of cardiology.

[41]  H. Mcgill,et al.  Atherosclerosis-related Responses to Cigarette Smoking in the Baboon , 1980, Circulation.

[42]  G. Klein,et al.  Anatomic substrate of impaired antegrade conduction over an accessory atrioventricular pathway in the Wolff-Parkinson-White syndrome. , 1980, Circulation.

[43]  R. Simon,et al.  The Effects of Intracoronary Nitroglycerin on Left Ventricular Systolic and Diastolic Function in Man , 1980, Circulation.

[44]  R. Havlik,et al.  Evidence for Additional Blood Pressure Correlates in Adults 20‐56 Years Old , 1980, Circulation.

[45]  O. Narula,et al.  Junctional Pacemakers in Man: Response to Overdrive Suppression With and Without Parasympathetic Blockade , 1978, Circulation.

[46]  J. Weiss,et al.  Leftward Septal Displacement During Right Ventricular Loading in Man , 1978, Circulation.

[47]  R. García,et al.  Recurrent atrial flutter. Treatment with a surgically induced atrioventricular block and ventricular pacing. , 1973, Archives of internal medicine.

[48]  Robert W. Anderson,et al.  Cryosurgical Ablation of Accessory Atrioventricular Connections: A Method for Correction of the Pre‐excitation Syndrome , 1977, Circulation.

[49]  J. Gallagher,et al.  Reaction of the myocardium and coronary arteries to cryosurgery. , 1977, Laboratory investigation; a journal of technical methods and pathology.

[50]  J. Gallagher,et al.  Surgical treatment of supraventricular tachyarrhythmias. , 1977, The Journal of thoracic and cardiovascular surgery.

[51]  V. Maranhao,et al.  Uncontrolled tachycardia in atrial fibrillation. Management by surgical ligature of A-V bundle and pacemaker. , 1974, The Annals of thoracic surgery.

[52]  L. Dreifus,et al.  Control of Recurrent Tachycardia of Wolff‐Parkinson‐White Syndrome by Surgical Ligature of the A‐V Bundle , 1968, Circulation.

[53]  N B Ingels,et al.  Evaluation of Methods for Quantitating Left Ventricular Segmental Wall Motion in Man Using Myocardial Markers as a Standard , 1980, Circulation.

[54]  M. Christensen,et al.  Optimal Diagnosis in Acute Myocardial Infarction: A Cost‐effectiveness Study , 1980, Circulation.

[55]  P. Coumel,et al.  Wolff‐Parkinson‐White Syndrome: Problems in Evaluation of Multiple Accessory Pathways and Surgical Therapy , 1972, Circulation.

[56]  W. Nichols,et al.  Use of Catheter‐tip. Velocity‐Pressure Transducer to Evaluate Left Ventricular Function in Man: Effects of Intravenous Propranolol , 1980, Circulation.

[57]  J. S. Cole,et al.  The Wolff‐Parkinson‐White Syndrome: Problems in Evaluation and Surgical Therapy , 1970, Circulation.

[58]  J. Stuckey,et al.  On the sympathetic control of ventricular automaticity. The effects of a reflex increase of sympathetic discharge. , 1969, The American journal of cardiology.

[59]  W. Kannel,et al.  Labile Hypertension: A Faulty Concept? The Framingham Study , 1980, Circulation.

[60]  The Effect of Transient Ischemia with Reperfusion on Thallium Clearance from the Myocardium , 1980, Circulation.

[61]  S. Ho,et al.  Straddling Right Atrioventricular Valves in Atrioventricular Discordance , 1980, Circulation.

[62]  M. Bourassa.  The Role of Bypass Surgery in Isolated Left Anterior Descending Artery Stenosis or Occlusion , 1980, Circulation.

[63]  J. F. Keane,et al.  Left Ventricular Function After Repair of Tetralogy of Fallot and Its Relationship to Age at Surgery , 1980, Circulation.

[64]  J. Wieberdink.  Experimental production of permanent heart block (total or bundle branch block) without circulatory arrest or extracorporeal circulation. , 1966, Thorax.

[65]  J. Goldberg,et al.  Ventricular Premature Complexes in Prognosis of Angina , 1980, Circulation.

[66]  J. Lablanche,et al.  Surgical Treatment of Variant Angina: Use of Plexectomy with Aortocoronary Bypass , 1980, Circulation.

[67]  E. Prystowsky,et al.  Origin of the Atrial Electrogram Recorded from the Esophagus , 1980, Circulation.

[68]  J. Gallagher,et al.  Reentry within the atrioventricular node: surgical cure with preservation of atrioventricular conduction. , 1979, Circulation.

[69]  M. Spach,et al.  Corrected transposition with severe intracardiac deformities with Wolff-Parkinson-White syndrome in a child. Electrophysiologic investigation and surgical correction. , 1980, Circulation.

[70]  A. Tonkin,et al.  Refractory Periods of the Accessory Pathway in the Wolff‐Parkinson‐White Syndrome , 1975, Circulation.

[71]  B. Massie,et al.  Beneficial Effects of Afterload Reduction Therapy in Patients with Congestive Heart Failure and Moderate Aortic Stenosis , 1980, Circulation.