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. 2013 Jan;165(1):87-92.
doi: 10.1016/j.ahj.2012.10.025. Epub 2012 Nov 20.

Multiple accessory pathways in the young: the impact of structural heart disease

Justin P Zachariah  1 , Edward P Walsh, John K Triedman, Charles I Berul, Frank Cecchin, Mark E Alexander, Laura M Bevilacqua
Affiliations

Multiple accessory pathways in the young: the impact of structural heart disease

Justin P Zachariah et al. Am Heart J. 2013 Jan.

Abstract

Background: The presence of multiple accessory pathways (MultAP) is described in structural heart disease (SHD) such as Ebstein's anomaly and cardiomyopathies. Structural defects can impact the tolerability of tachyarrhythmia and can complicate both medical management and ablation. In a large cohort of pediatric patients with and without SHD undergoing invasive electrophysiology study, we examined the prevalence of MultAP and the effect of both MultAP and SHD on ablation outcomes.

Methods: Accessory pathway number and location, presence of SHD, ablation success, and recurrence were analyzed in consecutive patients from our center over a 16-year period.

Results: In 1088 patients, 1228 pathways (36% retrograde only) were mapped to the right side (TV) in 18%, septum (S) in 39%, and left side (MV) in 43%. MultAP were present in 111 pts (10%), involving 250 distinct pathways. SHD tripled the risk of MultAP (26% SHD vs 8% no SHD, P < .001). Multivariable adjusted risk factors for MultAP included Ebstein's (OR 8.7[4.4-17.5], P < .001) and cardiomyopathy (OR 13.3[5.1-34.5], P < .001). Of 1306 ablation attempts, 94% were acutely successful with an 8% recurrence rate. Ablation success was affected by SHD (85% vs 95% for no SHD, P < .01) but not by MultAP (91% vs 94% for single, P = .24). Recurrence rate was higher for SHD (17% SHD vs 8% no SHD, P < .05) and MultAP (19% MultAP vs 8% single, P < .001).

Conclusions: MultAP are found in 10% of pediatric patients, and are more common in SHD compared to those with normal hearts. Both the presence of MultAP and SHD negatively influence ablation outcomes.

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Conflict of interest statement

No author has a conflict of interest to declare regarding this work.

Figures

Figure 1
Figure 1
Depiction of each pathway in SHD patients by 13 location segments: anterior, anterolateral, lateral, posterolateral, and posterior locations along the tricuspid (TV) or mitral valve (MV); or along anterior, mid, or posterior septum. Panel a) Ebstein’s anomaly; b) AV Discordance with left-sided tricuspid valve; c) Myopathy; and d) “Other” structural heart disease. Solid circles indicate pathway locations in multAP patients while open circles indicate single pathways.
See this image and copyright information in PMC

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