TY - JOUR
T1 - Miniseries 2-Septal and paraseptal accessory pathways-Part II: Para-Hisian accessory pathways-so-called anteroseptal pathways revisited
AU - Farre, Jeronimo
AU - Anderson, Robert H.
AU - Sanchez-Quintana, Damian
AU - Mori, Shumpei
AU - Rubio, Jose-Manuel
AU - Garcia-Talavera, Camila
AU - Bansal, Raghav
AU - Lokhandwala, Yash
AU - Cabrera, Jose-Angel
AU - Wellens, Hein J. J.
AU - Sternick, Eduardo Back
PY - 2022/4/5
Y1 - 2022/4/5
N2 - Surgeons, when dividing bypass tracts adjacent to the His bundle, considered them to be 'anteroseptal'. The area was subsequently recognized to be superior and paraseptal, although this description is not entirely accurate anatomically, and conveys little about the potential risk during catheter interventions. We now describe the area as being para-Hisian, and it harbours two types of accessory pathways. The first variant crosses the membranous septum to insert into the muscular ventricular septum without exiting the heart, and hence being truly septal. The second variant inserts distally in the paraseptal components of the supraventricular crest, and consequently is crestal. The site of ventricular insertion determines the electrocardiographic expression of pre-excitation during sinus rhythm, with the two types producing distinct patterns. In both instances, the QRS and the delta wave are positive in leads I, II, and aVF. In crestal pathways, however, the QRS is >= 140 ms, and exhibits an rS configuration in V1-2. The delta wave in V1-2 precedes by 20-50 ms the apparent onset of the QRS in I, II, III, and aVF. In the true septal pathways, the QRS complex occupies similar to 120 ms, presenting a QS, W-shaped, morphology in V1-2. The delta wave has a simultaneous onset in all leads. Our proposed terminology facilitates the understanding of the electrocardiographic manifestations of both types of para-Hisian pathways during pre-excitation and orthodromic tachycardia, and informs on the level of risk during catheter ablation.
AB - Surgeons, when dividing bypass tracts adjacent to the His bundle, considered them to be 'anteroseptal'. The area was subsequently recognized to be superior and paraseptal, although this description is not entirely accurate anatomically, and conveys little about the potential risk during catheter interventions. We now describe the area as being para-Hisian, and it harbours two types of accessory pathways. The first variant crosses the membranous septum to insert into the muscular ventricular septum without exiting the heart, and hence being truly septal. The second variant inserts distally in the paraseptal components of the supraventricular crest, and consequently is crestal. The site of ventricular insertion determines the electrocardiographic expression of pre-excitation during sinus rhythm, with the two types producing distinct patterns. In both instances, the QRS and the delta wave are positive in leads I, II, and aVF. In crestal pathways, however, the QRS is >= 140 ms, and exhibits an rS configuration in V1-2. The delta wave in V1-2 precedes by 20-50 ms the apparent onset of the QRS in I, II, III, and aVF. In the true septal pathways, the QRS complex occupies similar to 120 ms, presenting a QS, W-shaped, morphology in V1-2. The delta wave has a simultaneous onset in all leads. Our proposed terminology facilitates the understanding of the electrocardiographic manifestations of both types of para-Hisian pathways during pre-excitation and orthodromic tachycardia, and informs on the level of risk during catheter ablation.
KW - Pre-excitation
KW - Accessory pathway
KW - Electrocardiogram
KW - Para-Hisian pathway
KW - Anteroseptal pathway
KW - Superoparaseptal pathway
KW - Intermediate septal pathway
KW - Mid-paraseptal pathway
KW - Midseptal pathway
KW - CATHETER ABLATION
KW - ELECTROCARDIOGRAPHIC CHARACTERISTICS
KW - FREE-WALL
KW - LOCALIZATION
KW - ANTERIOR
KW - ANATOMY
U2 - 10.1093/europace/euab293
DO - 10.1093/europace/euab293
M3 - Article
C2 - 34999787
SN - 1099-5129
VL - 24
SP - 650
EP - 661
JO - EP Europace
JF - EP Europace
IS - 4
ER -