This document discusses different types of arrhythmias including tachycardia, supraventricular tachycardia, ventricular tachycardia, ventricular fibrillation, and atrial fibrillation. It describes the anatomical locations and electrical physiology of various arrhythmias. Treatment options are provided for different arrhythmias including medications, cardioversion, ablation procedures, and implantable cardioverter defibrillators. Specific arrhythmias like idiopathic ventricular tachycardia, torsades de pointes, Brugada syndrome, and catecholaminergic polymorphic ventricular tachycardia are also explained.

1. Arrhythmia ECG
Tachycardia
林亮宇
台大醫院 科部內

2. Tachycardia
Surpa-ventricular tachycardia
Ventricular tachycardia
Ventricular fibrillation

3. Supra-ventricular tachycardia
From atria
-Atrial tahycardia: 100-250/min
-Atrial flutter: 250-350/min
-Atrial fibrillation > 350/min
From AV junction: Junctional tachycardia
Atrioventricular nodal reentrant tachycardia
(AVNRT)
Atrioventricular reciprocating tachycardia (AVRT)

4. PSVT 之電生理分類：
1. 與 sinus node 有關者
sinus tachycardia
sinus node reentry tachycardia ( SAT )
2. 與 AV node 有關者
AV nodal reentry tachycardia ( AVNRT )
AV reentry tachycardia ( AVRT ) using
accessory pathway

6. AVNRT: Slow-Fast (Common), Fast-Slow (Uncommon)
No “ P ” in Common Type, Clear “ P’ ” in Uncommon
Type

7. AV NODAL EXTENSIONSAV NODAL EXTENSIONS
CS OS
Anterior
extension Posterior
extension
Tricuspid
hinge

8. Pre-excitationPre-excitation

9. Anatomical locations of Right vs. Left Accessory Pathways

10. Pre-excitationPre-excitation

11. Wide-Complex Tachycardia, r/o VT
Sinus Rhythm AVRT, Antidromic

12. Ebstein’s Anomaly, WPW Syndrome

13. Avoid CCB, BB, digoxin

14. PSVT 之電生理分類 ：
3. 與 atrial muscle 有關者
Atrial tachycardia
Atrial flutter
Atrial fibrillation

15. “AT” in A SSS Patient :
Focal AT in RA

16. Atrial flutter

17. Typical Atrial Flutter: circuit & ablation
IVCO-TA
isthmus

18. Focal to chaotic Atrial Fibrillation
Cont’d.

19. 陣發 持續

20. Circumferential PV isolation by RFCA
Pappone C, Circulation 2000.

21. AVNRT, AVRT: carotid massage, adenosine, CCB, BB
AT, AF, Afib
Rate control: CCB, BB, digoxin, amiodarone
Rhythm control (within 48 hrs and for prophylatic):
-Class IA: quinidine
-Class IC: propafenone
-Class III: amiodarone
Cardioversion
Low perfusion
AF, Afib within 48 hrs (TEE/anticoagulant)
Prevention of embolism AF, Afib
RFCA for AVNRT, AVRT, AT, AF and Afib?
Management of SVT

22. Ventricular tachycardia
Idiopathic VT
-From RVOT
-From LV inferioapical septal region: ILVT
Organic VT
CAD
CHF
Cardiomyopathy: HCM, DCM,

23. VTVT

24. ECG of VT
Wide QRS complex (most VT)
Must be VT
VA block
Capture beat or fusion beat
Morphological criteria: favor VT
Precordial concordance
QRSd>140ms

25. VT: AV dissociationVT: AV dissociation

26. VT:VT:
positive &positive &
negativenegative
concordanceconcordance

27. Capture beatCapture beat

28. Idiopathic Ventricular TachycardiaIdiopathic Ventricular Tachycardia
DefinitionDefinition : ventricular arrhythmia that: ventricular arrhythmia that
originate in hearts without structuraloriginate in hearts without structural
diseasedisease
Right/ left ventricular outflow tract VTRight/ left ventricular outflow tract VT
(Adenosine- sensitive VT)(Adenosine- sensitive VT)
Left ventricular fascicular tachycardiaLeft ventricular fascicular tachycardia
(Verapamil- sensitive VT)(Verapamil- sensitive VT)

29. • MostMost
common:common:
RVOT,RVOT,
LBBB andLBBB and
inferior axisinferior axis
• LessLess
common:common:
LVOT:LVOT:
RBBB andRBBB and
inferior axisinferior axis

30. Idiopathic Left Ventricular Tachycardia
A-V Dissociation, RBBB and Superior Axis Favors VT,

31. Idiopathic Left Ventricular Tachycardia
A-V Dissociation, RBBB and Superior Axis Favors VT,

32. Management of VT
Idiopathic VT
-RVOT: adenosine or verapamil
-ILVT: verapamil
-Both amenable to RFCA
Organic VT
DC shock
Medication: Ib (lidocaine, mexitil), III (amiodarone, sotalol)
ICD, RFCA

33. Postulated Reentry Circuit in Post-Infarct VT (Stevenson WG, 1993)

34. Torsade de Pointes (TdP)
Long QT related
Early after depolarization (EAD)
R on T
Congenital or acquired (mostly drug)-

35. Female, 22 y/o

36. Torsade de PointesTorsade de Pointes

37. Management of TdP
Overdrive pacing
Isoproterenol
MgSO4
Beta-blockers
Remove offending agents
anti-histamine, antifungal, macrolide, AAD

38. With Structural heart disease
HCM, ARVD
Without structural heart disease
Long (short) QT syndrome: NA, KChannelopathy
Brugada syndrome: Na channel defect
Catecholaminergic polymoprhic VT: Ryanodine Rdefect
Hereditary SCD syndrome

39. Antzelevitch et al, JACC 2003; 41: 1665-71
Brugada Syndrome

40. Male, 32 y/o, Recurrent Seizures
Brugada Syndrome : VF

41. V1
II
V5
aVF
V4
V6
CPVT Catecholaminergic Polymorphic Ventricular Tachycardia
Ryanodine receptor ( RyR2 ) mutation, rise of Ca i

42. Bi-directional VT: digoxin intoxication

43. Ventricular FibrillationVentricular Fibrillation

44. ICDindication forSCDprevention in:
 Post-Infarction
 Cardiomyopathy, ARVD
 Heart failure
 Brugada /LQTS/CPVT/SQTS
 Idiopathic VF

45. Thank you for your
attention