Transient Complete Heart Block During

Radiofrequency Ablation of a Left Lateral Bypass

Tract
NICHOLAS J. STAMATO, STEVEN L. EDDY, and DEBRA J. WHITING
From the Cardiac Electrophysiology Laboratory. Wilson Memorial Regional Medical Center,
United Health Services Hospitals Inc., Johnson City, New York

STAMATO, NJM ET AL.: Transient Complete Heart Block During Radiofrequency Ablation of a Left Lat-
eral Bypass Tract. RF catheter ablation of accessory bypass tracts associated with the Wolff-Parkinson-
White syndrome has become an accepted and widespread therapy. When bypass tracts are located in the
free wall of the left ventricle, a single catheter technique may be utilized. A single catheter is placed via
the femoral artery, across the aortic valve into the left ventricle. Mapping is performed during sinus
rhythm, and ablation performed at the site of recording of Kent bundle activation. We describe a case of
a patient with Wolff-Parkinson-White syndrome presenting with rapid atrial fibrillation requiring car-
dioversion. This patient subsequently underwent catheter ablation of a left free-wall bypass tract using the
single catheter technique. At baseline, preexcitation and right bundle branch block (RBBB) were present
on the ECG. During catheter ablation of the accessory pathway, transient complete AV block was seen.
This was felt likely to be due to trauma to the His bundle, or more likely to the left bundle branch, as the
ablation catheter crossed the aortic valve. The bypass tract was successfully ablated after placement of a
temporary right ventricular pacemaker. AV conduction resumed with a pattern of RBBB. A temporary
right ventricular pacing catheter should be placed prior to RF ablation of left-sided bypass tracts when the
ECG is also suggestive ofBBBB. (PAGE 1996; 19:1351-1354)

Wolff-Parkinson- White, ablation

Introduction formed to ensure that no other anomalous atri-

Radiofrequency (RF) catheter ablation has
hecome accepted and widespread as a therapy
for a variety of supraventricular arrhythmias, in-
cluding the Wolff-Parkinson-White syn-
drome.^"^ This procedure is often performed at
the same time as diagnostic electrophysiological
studies.^ Some authors have proposed a tech-
nique for ahlation of left free-wall hypass tracts
that utilizes a single catheter.'' The femoral
artery and a transaortic valve approach are used,
and mapping is performed of the left ventricle-
left atrial annulus during sinus rhythm in pa-
tients with overt preexcitation. Postablation
testing using atrial and ventricular pacing is per-
oventricular (AV) connections are present. This
technique has been reported to be associated
with a shorter procedure time and relatively few
complications."^'^
We report an unusual transient complication
in which a patient with Wolff-Parkinson-White
syndrome and preexisting right bundle branch
block (RBBB) developed transient complete heart
hlock during single catheter RF ablation of a left
free-wall bypass tract far removed from the normal
AV conduction system.
We suggest that when such a combination is
seen, that right ventricular temporary pacing be
prophylactically utilized prior to ablation of left
free-wall bypass tracts.

Address for reprints: Nicholas J. Stamato, M.D.. Director of Case Report

Electrophysiology, Wilson Memorial Regional Modical Center,
30 Harrison Street, Suite 250, fiihn.son City. NY 13790-2143. A 50-year-old man had presented witb rapid
Fax: (607) 770-0853. atrial fibrillation and ventricular preexcitation.
Received July 18, 1994; accepted August 30, 1994. This had caused syncope and required electrical

PACE, Vol. 19 September 1996 1351

 STAMATO, ET AL.

Figure 1. The 12-lead ECG during sinus rhythm, show-

ing preexcitation and terminal QRS delay compatible Figure 3. Flunroscopic image in tho left anterior
with RBBB. oblique view of the ablation catheter (open arrow) and
the right ventricular apex pacing catbeter (arrow).

cardioversion in the emergency department. He
was treated with oral procainamide and was dis-
charged. The patient remained free of symptoms
until the development of arthralgias and myalgias,
which were felt secondary to the procainamide.
RF catheter ahlation was recommonded. A sinus
rhythm ECG had a pattern of preexcitation com-
patible with a left free-wall bypass tract. Also pre-
sent was a pattern of terminal QRS delay nompat-
ihle with RBBB (Fig. 1). A baseline electro-
physiology study was done with the patient off of
all antiarrhythmic drugs, during which atrial fib-
rillation, but not AV reentry was induced. During
atrial fibrillation, nonpreexcited beats revealed an

Figure 4. The recordings made from the ablation

Figure 2. The 12-lead ECG during atrial fibrillation at
electrophysiology study while on no medication. The
asterisk represents the nonpreexcited beat demonstrat-
ing BBBB.
catheter within the left ventricle (same site as in Fig. 3).
I, II III. aVR. aVF. and VI are surface leads. ABLATION
~ bipolar electrogram from the distal electrode pair of
the catheter: BPT = electrogram from the proximal elec-
trode pair.

1352 September 1996 PACE, Vol. 19

 HEART BLOCK DURING WPW ABLATION
pn"""Tr^'["v'i'ri'i'''t'r rmrinr n'l 'p'l' I'f 'T ff i wr i"' i 'rn' i'|'
Figure 5. Recordings mode during RF energy applica-
tion at the site of Figures 3 and 4, demonstrating com-
plete heart block (CHR).
RBBB pattern {Fig. 2). Sinus rhythm mapping con-
firmed a single left free-wall bypass tract.
The patient was returned to lahoratory on an-
other day for planned single catheter RF ablation.
A sheath was placed in the right femoral artery,
through which a large tip mapping catheter (Bard
Electrophysiology, Haverhill, MA, USA) was
placed across the aortic valve into the left ventri-
cle (Fig, 3). Mapping of the AV annulus revealed a
site in the left ventricular free wall, far removed
from the normal mid-line conduction system,
where a Kent potential could be recorded (Fig. 4).
RF energy (Radionics, Burlington, MA, USA) was
delivered though the distal electrode at a setting of
35 V. Two seconds after the onset of RF energy de-
livery, complete AV hlock was noted. RF energy
was discontinued and AV conduction with preex-
citation resumed (Fig. 5). A temporary pacing
catheter was placed into the right ventricular
apex. Two further applications of RF energy with
settings at 35 V for 45 seconds were delivered,
successfully abolishing preexcitation without
moving the ablation catheter from its original lo-
cation. AV conduction with RBBB was seen dur-
ing the subsequent RF applications. The left ven-
tricular catheter was removed, and atrial and
ventricular pacing and His-bundle recordings
were performed. AV conduction intervals were
found to be within normal limits, with a sinus cy-
cle length of 858 ms, an AH equal to 66 ms, HV
PACE. Vol. 19
equal to 54 ms, and AV Wenckebach seen at a cy-
cle length of 390 ms.
All catheters were removed, and the patient
was observed on telemetry for 24 hours, during
which AV conduction with RBBB was seen. The
patient was discharged home and has remained
asymptomatic with follow-up ECGs continuing to
show no evidence of preexcitation and continued
RBBB.
Discussion
While a variety of complications have been
described in patients undergoing RF ablation for
Wolff-Parkin son-White syndrome, complete heart
block has not been associated with ablation of left
free-wall bypass tracts. While this has been seen
in patients undergoing ablation of AV nodal reen-
try or septal bypass tracts, this is clearly an un-
usual event in patients undergoing ablation of left
free-wall bypass tracts.
While the identification of RBBB in patients
with overt left lateral bypass tracts may be prob-
lematic, the presence of terminal delay with deep,
broad S waves in leads I and Ve is suggestive. The
appearance of the QRS during atrial fibrillation
during nonpreexcited beats is also supportive.
The mechanism of the transient complete
heart block in this case is felt to be due to trauma
to the left bundle branch as the ablation catheter
crossed the aortic valve. As is seen in Figure 3, the
catheter lies near the His bundle and proximal left
bundle region as it crosses the aortic valve. This is
retrospectively recognized when comparing the
QRS morphology in Figures 1 and 4. In the latter,
full preexcitation is present with an Rsr' pattern in
Vi compared with the rsR' pattern present at base-
line. We feel this is due to complete heart block in
the normal conduction system prior to the deliv-
ery of RF energy. While trauma to the His bundle
could also account for these findings, it would
seem less likely, as such would occur with or
without RBBB and is rare.
The events in the patient described in this re-
port with the utilization of a single catheter tech-
nique could be associated with devastating conse-
quences if temporary pacing were not
immediately available. It should be noted that this
patient had transcutaneous pacing and defibrillat-
ing pads applied and, if necessary, temporary pac-
September 1996 1353
 STAMATO, ET AL.

ing could bave been performed. Also, pacing
tbrougb tbe ablation catheter could have been per-
formed; bowever, transvenous pacing would be
preferable.
We suggest tbat in patients with preexcitation
due to left free-wall bypass tracts and an ECG pat-
tern suggestive of RBBB, a right ventricular
catheter ought to be placed in order to serve as a
temporary pacemaker if needed dnring catheter
ablation.

References
Jackman W, Xang X, Friday K. et al. Catheter abla-
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Calkins H, Sousa J, Rosenbeck S, et al. Diagnosis
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1354 September 1996 PACE. Vol. 19