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Para-Hisian pacing: Useful clinical technique to differentiate retrograde conduction between accessory atrioventricular pathways and atrioventricular nodal pathways

  • Hiroshi Nakagawa
    Correspondence
    Address reprint requests and correspondence: Hiroshi Nakagawa, MD, PhD, Cardiac Arrhythmia Research Institute, University of Oklahoma Health Sciences Center, 1200 Everett Drive (TUH-6E-103), Oklahoma City, OK 73104.
    Affiliations
    Cardiac Arrhythmia Research Institute, Department of Medicine University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
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  • Warren M. Jackman
    Affiliations
    Cardiac Arrhythmia Research Institute, Department of Medicine University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
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      Para-Hisian pacing is a useful tool to differentiate between retrograde conduction over an accessory pathway and retrograde conduction over the fast or slow atrioventricular (AV) nodal pathways.
      • Jackman W.M.
      • Beckman K.J.
      • McClelland J.
      • Wang X.
      • Hazlitt A.
      • Moulton K.
      • Prior M.
      • Twidale N.
      • Calame J.
      • Lazzara R.
      Para-Hisian RV pacing site for differentiating retrograde conduction over septal accessory pathway and AV node.
      • Jackman W.M.
      • Wang X.
      • Friday K.J.
      • Roman C.A.
      • Moulton K.P.
      • Beckman K.J.
      • McClelland J.H.
      • Twidale N.
      • Hazlitt H.A.
      • Prior M.I.
      • Margolis P.D.
      • Calame J.D.
      • Overholt E.
      • Lazzara R.
      Catheter ablation of accessory atrioventricular pathways (Wolff-Parkinson-White syndrome) by radiofrequency current.
      • Hirao K.
      • Otomo K.
      • Wang X.
      • Beckman K.J.
      • McClelland J.H.
      • Widman L.
      • Gonzalez M.D.
      • Arruda M.
      • Nakagawa H.
      • Lazzara R.
      • Jackman W.M.
      Para-Hisian pacing a new method for differentiating retrograde conduction over an accessory AV pathway from conduction over the AV node.
      Para-Hisian pacing uses right ventricular (RV) pacing close to the His bundle or proximal right bundle branch (RBB). As the position of the ventricular pacing catheter changes subtly during respiration (or by changing pacing output), the pacing stimulus changes capture among (1) basal anteroseptal RV plus His bundle or proximal RBB (His bundle-RBB capture); (2) capture of basal anteroseptal RV alone; and (3) His bundle-RBB capture alone. These changes in pacing capture result in abrupt changes in the timing of His bundle activation relative to the timing of ventricular activation. The presence or absence of a change in atrial activation sequence, stimulus-atrial (SA) intervals, and His bundle-atrial (HA) interval identifies whether retrograde conduction is dependent on ventricular activation (retrograde conduction over an accessory pathway) or His bundle activation (retrograde conduction over the AV node) or both (accessory pathway and AV node; Figure 1, Figure 2). The loss of His bundle-RBB capture is usually identified by the widening of the QRS complex, indicating that some of the ventricular myocardium (farthest from the RV basal septal pacing site) is activated by the His-Purkinje system during both RV and His bundle-RBB capture.
      Figure thumbnail gr1
      Figure 1Schematic representation of response to para-Hisian pacing between conduction over the AV node alone (A), conduction over an accessory pathway alone (B), and conduction over the AV node and accessory pathway combined (C).
      Figure thumbnail gr2
      Figure 2Algorithm for interpretation of the response to para-Hisian pacing (see text for explanation).
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