Differentiation between AVNRT and AVRT_advanced lecture


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Differentiation between AVNRT and AVRT_advanced lecture

  1. 1. Advanced AVNRT and AVRT With differentiation Advanced EP Training (中華民國心律醫學會) 謝敏雄 醫師 台北醫學大學醫學系副教授 萬芳醫院心臟內科主任 April 24, 2011 於台北國際飯店
  2. 2. Supraventricular tachycardia (SVT) • Etiology: (臺北榮總十三年經驗) 1. AVNRT (n=1452): 50% Typical (slow-fast) 90% Atypical (fast-slow) 7% Variant (intermediate) 9% 2. AVRT (n=1221): 42% orthodromic (fast AP 90% or slow AP 10%) 3. AT (n=245): 8%
  3. 3. 12-lead ECG fordifferential diagnosis of SVTs (important!)
  4. 4. Retrograde P wave in SVT (Tai CT et al. JACC 1997)
  5. 5. Short RP SVT1. Slow-Fast AVNRT: No apparent retrograde P wave: 50% Pseudo R’ in V1 or pseudo-S in inferior leads: 50%2. Orthodromic AVRT: 70 ms<RP<PR The presence of delta wave in NSR.3. AT with PR prolongation: the presence of AV block favors AT.
  6. 6. S-F AVNRT Pseudo-R’Pseudo-S
  7. 7. NSR after IV adenosine No pseudo-R’ and pseudo-S
  8. 8. S-F AVNRT No apparent P wave
  9. 9. S-F masked by QRSP wave AVNRT
  10. 10. S-F AVNRTPseudo-R’ and pseudo-S
  11. 11. S-F AVNRTPseudo-R’ and pseudo-S
  12. 12. Orthodromic AVRT RP>70 ms, favor LL AP
  13. 13. MWPW (LL or LAL AP)
  14. 14. Long RP SVT1. Fast-Slow AVNRT: Positive p wave in V1 and negative p wave in inferior leads.2. Orthodromic AVRT using decremental (slow) APs.3. AT with normal PR interval.
  15. 15. EP study fordifferential diagnosis of SVTs
  16. 16. Favors AVNRT1. The presence of dual AVN physiology: upper or lower common pathway.2. The critical prolongation (jump) of AH interval during the initiation of SVT.3. The concentric atrial activation: especially a straight line from ECG-A-V or A before V (SF AVNRT)
  17. 17. AVNRT• Antegrade SAVN: AH jump > 50 ms• Continuous curve AVNRT• Retrograde SAVN:1.Long VA interval2.CSO-A earliest.• Retrograde intermediate AVN:1.Intermediate VA interval2.His-A and CSO-A both earlier• AVNRT with retrograde eccentric activation
  18. 18. Continuous curve AVNRT (Tai CT et al. Circulation 1997)
  19. 19. Initiation of S-F AVNRT Progressive AH prolongation with jump
  20. 20. Lower common of VA interval Progressive prolongation pathway V A V AV AV A
  21. 21. AVNRT with eccentric A activation (Ong M. et al. IJC 2007)
  22. 22. Favors AVRT1. No decremental conduction during pacing (except slow AP).2. The eccentric atrial activation with short VA interval (>70 ms)3. VA interval increases >30 ms with functional BBB.
  23. 23. LT AP with LBBB (Josephson ME. P237)
  24. 24. Single VPC reset SVT
  25. 25. His refractory VPC• 35-55 ms before the His deflection.• Advance the following A: AVRT• VPC without conducting to atrium but terminate the SVT: rule out AT.• VPC from the sites other than RVA: LV: for left side APs RVOT: for septal APs
  26. 26. Ventricular Overdrive Pacing (VOP) (10-40 msshorter than tachycardia) during SVT
  27. 27. VOP entrains the SVT• VOP could not entrain SVT: AT• The same atrial activation sequence: AVNRT or AVRT The different atrial activation sequence: AT• The presence of lower common pathway: AVNRT is more likely.• The presence of V-A-A-V response: AT• The presence of V-A-V response: favors AVNRT or AVRT.
  28. 28. VOP during SVT A A V V AT1. The retrograde A sequence is different during tachycardia and VOP2. The presence of V-A-A-V response during VOP (Veenhuyzen G. et al. PACE 2011)
  29. 29. Para-Hisian pacingHirao, K. et al. Circulation 1996;94:1027-1035
  30. 30. Ablation Strategy of AVNRT• Make a correct diagnosis!!!• Ablation of slow or intermediate AVN1. Anatomic approach: P M A2. Electrogram approach: small A, large V3. JT during RF• How to avoid AV block?1. ablation during A pacing2. avoid ablation during SVT or V pacing.3. You have only one second to stop RF!!!
  31. 31. JT under during RF
  32. 32. Transient second degree AVB
  33. 33. Flat and horizontal Koch’s Triangle RAO LAO (Lee PC et al. Curr Opin Cardiol. 2009)
  34. 34. Ablation Strategy of AVRT• Make a correct diagnosis!!!• Localization of the APs: 12-lead ECG algorithm and intracardiac recordings.• Antegrade approach: for RT AP• Retrograde approach: for LT AP1. V site (subvalvular): small A, large V, stable ablation catheter2. A site (ante- or retro-grade): larger A, unstable ablation catheter
  35. 35. Delta Wave in NSR (Chiang CE et al. AJC 1996)
  36. 36. What’s on the other side 背面是啥米碗糕
  37. 37. 這是真的呀
  38. 38. Cases Discussion
  39. 39. Case 1VT, PSVT with RBBB or preexcitated tachycardia?
  40. 40. RA burst + Isuprel induce SVT What’s the mechanism of SVT? AVNRT with Wenkebach AV block then 1:1 conduction
  41. 41. S-F AVNRT
  42. 42. PSVT with LBBB
  43. 43. RVS1S2 induced PSVT 500 270
  44. 44. Retrograde-intermediate AVN or AP? AH=188 ms HA=158 ms
  45. 45. VPC terminate SVT: AVN or AP? 347 ms 347 ms 293 ms
  46. 46. V pacing during SVT: AVN or AP? 372 ms 350 ms Lower common pathway
  47. 47. Mapping retrograde pathway and terminate SVT (after ablation of antegrade SAVN)
  48. 48. RAO LAO• Ablation of Antegrade SAVN• Ablation of retrograde intermediate AVN
  49. 49. Case 2A 28 Y/O male fireman had recurrent attacks of tachycardia during exercise RVOT-VT, PSVT with LBBB or Preexcited tachycardia?
  50. 50. NSR (Intermittent Preexcitation) AP location?
  51. 51. RVS1S1 350 ms 350
  52. 52. RVS1S1 340 ms Favors AP Sudden VA block 340
  53. 53. RVS1S2 500/310 ms F-S echo
  54. 54. RAS1S2 Induced Tachycardia Wide QRS complex tachycardia: VT?, or Preexcitated tachycardia? PSVT with LBBB
  55. 55. Wide QRS Tachycardia TCL= 256 ms
  56. 56. Question?• What’s the mechanism of Wide QRS complex tachycardia? VT? Preexcitated tachycardia? PSVT with LBBB? PSVT with LBBB• What’s the next step to D.D?
  57. 57. VPC terminate tachycardia Without conduction to A VPC Can rule out AT
  58. 58. VOP terminate tachycardia Sudden VA block The same A sequence No lower common pathway AVNRT is not likely
  59. 59. Initiation of NQRS tachycardia
  60. 60. NQRS TachycardiaTCL= 244 ms shorter than SVT with LBBB (256 ms) Favor left side AP?
  61. 61. VPC reset SVT 248 233 His refractory VPC
  62. 62. Ablation site: RPS
  63. 63. Success within 5 seconds RF on VA block
  64. 64. Immediate recurrence within 5” RF off
  65. 65. Ablation site 1: RPS
  66. 66. Success within 3 seconds VA block
  67. 67. Immediate recurrence within 3”
  68. 68. Ablation site 2: RPS
  69. 69. Ablation site: LMS
  70. 70. Success within 5 seconds VA block
  71. 71. Ablation site 3: LMS
  72. 72. Transient CAVB
  73. 73. PS APs (Chiang CE et al. Circulation 1996)
  74. 74. MS APs(Chang SL et al. JCE 2005)
  75. 75. Small & narrow P wave RA & LA depolarization simultaneouslyTest A P wave in the midpoint between the two QRS beats Diagnosis: SF AVNRT with 2:1 AV block
  76. 76. TestAT with 2:1 AV block?What’s the next step?
  77. 77. Test: VOP 2:1 to 1:1 conduction
  78. 78. 謝謝聆聽敬請指教