What is the clinical evidence from this study?

Study design: Observational. Population: Atrioventricular nodal reentrant tachycardia (AVNRT) (n=28). Intervention: Low-voltage bridge (LVB) strategy vs. Sinus rhythm propagation mapping (SRPM). Primary outcome: Identification of the effective cryoablation site when SRPM and LVB were in different locations.

What question did this study set out to answer?

This study aims to explore the connection between sinus rhythm propagation and low-voltage bridge strategies in pediatric AVNRT patients.

April 18, 2026Open Access

Sinus Rhythm Propagation and Low-Voltage Bridge in Koch’s Triangle: How They Relate in Cryoablation of Atrioventricular Nodal Reentry Tachycardia in Children

Key Result

The low-voltage bridge strategy identified the effective cryoablation site in more discordant cases than sinus rhythm propagation mapping in pediatric AVNRT patients (50.0% vs 12.5%).

Key Points

This study aims to explore the connection between sinus rhythm propagation and low-voltage bridge strategies in pediatric AVNRT patients.
Retrospective review of pediatric patients undergoing cryoablation for AVNRT assisted by 3D electroanatomical mapping.
Assessment of LVB strategy and sinus rhythm propagation mapping.
Evaluation of collision areas in relation to effective cryoablation sites.
Atypical sinus rhythm propagation was noted in 35.7% of patients.
Concordance between sinus rhythm propagation and low-voltage bridge was imperfect in only 10 out of 18 patients.
LVB identified effective cryoablation sites more often than sinus rhythm propagation mapping.

Study Design

Type

Observational (n=28)

Structured PICO

Does the low-voltage bridge (LVB) strategy correlate better with the effective cryoablation site than sinus rhythm propagation mapping (SRPM) in pediatric patients with AVNRT?

Population

28 pediatric patients (mean age 11.3 ± 3.3 years) who underwent cryoablation for atrioventricular nodal reentrant tachycardia (AVNRT) assisted by high-density 3D electroanatomical mapping using the low-voltage bridge (LVB) strategy.

Intervention

Retrospective analysis of sinus rhythm propagation mapping (SRPM) compared to the low-voltage bridge (LVB) strategy during cryoablation.

Outcome

Concordance between SRPM and LVB, and identification of the effective cryoablation site.surrogate

In pediatric patients undergoing cryoablation for AVNRT, the low-voltage bridge strategy showed closer concordance with the successful ablation site than retrospectively reconstructed sinus rhythm propagation mapping.

Main Result

Absolute Event Rate: 50% vs 12.5%

Abstract

Background/Objectives: Transcatheter ablation assisted by three-dimensional (3D) electroanatomical mapping (EAM) is the elective treatment for atrioventricular nodal reentrant tachycardia (AVNRT) in children and adolescents. In this population of patients, the most frequently employed EAM strategies are the low-voltage bridge (LVB) strategy and sinus rhythm propagation mapping (SRPM). However, the exact pathophysiology and anatomy of the AVNRT reentrant circuits are still poorly understood. The aim of this study was to investigate the relationship between SRPM and LVB and to shed light on nodal physiology in children and adolescents affected by AVNRT. Methods: We retrospectively collected data on pediatric patients who underwent cryoablation for AVNRT assisted by high-density 3D EAM by using the LVB strategy; maps were reviewed by two independent electrophysiologists and the SRPM was described. SRPM was defined as typical when only one collision area was identified and atypical whenever either no or ≥ two collision areas were localized. Results: Twenty-eight consecutive patients (11.3 ± 3.3 years) were enrolled. All procedures were acutely successful. Overall, atypical SRPM was present in 10 patients (35.7%), and it did not correlate with the presence of multiple SPs or electrophysiological data. Moreover, we observed an imperfect concordance between SRPM and LVB (only in 10/18 patients). When SRPM and LVB were assessed in different locations, the LVB identified the effective cryoablation site in more cases than SRPM (4/8 vs. 1/8). Lastly, in cases of double collision, one collision area co-localized with the LVB and the effective cryoablation spot, whereas the other was located superiorly, closer to the His bundle. Conclusions: Atypical sinus rhythm propagation in the Koch’s triangle is a frequent finding in pediatric AVNRT patients. In this series, LVB showed closer concordance with the successful cryolesion site than retrospectively reconstructed SRPM.