1. This document provides an overview of a training course on complex supraventricular tachycardia (SVT) differentiation. It discusses various SVT etiologies and electrocardiogram patterns.
2. Mechanisms of SVT discussed include atrioventricular nodal reentrant tachycardia (AVNRT), atrioventricular reentrant tachycardia (AVRT), and atrial tachycardia (AT). The document also reviews electrophysiology study findings that help differentiate the mechanisms.
3. Case examples are presented to demonstrate electrophysiology study techniques for SVT diagnosis and ablation, including ventricular overdrive pacing, ventricular extrastimuli, and induction protocols.
AV nodal reentrant tachycardia (AVNRT), or atrioventricular nodal reentrant tachycardia, is a type of tachycardia (fast rhythm) of the heart. It is a type of supraventricular tachycardia (SVT), meaning that it originates from a location within the heart above the bundle of His. AV nodal reentrant tachycardia is the most common regular supraventricular tachycardia. It is more common in women than men (approximately 75% of cases occur in females). The main symptom is palpitations. Treatment may be with specific physical maneuvers, medication, or, rarely, synchronized cardioversion. Frequent attacks may require radiofrequency ablation, in which the abnormally conducting tissue in the heart is destroyed.
AVNRT occurs when a reentry circuit forms within or just next to the atrioventricular node. The circuit usually involves two anatomical pathways: the fast pathway and the slow pathway, which are both in the right atrium. The slow pathway (which is usually targeted for ablation) is located inferior and slightly posterior to the AV node, often following the anterior margin of the coronary sinus. The fast pathway is usually located just superior and posterior to the AV node. These pathways are formed from tissue that behaves very much like the AV node, and some authors regard them as part of the AV node.
The fast and slow pathways should not be confused with the accessory pathways that give rise to Wolff-Parkinson-White syndrome (WPW syndrome) or atrioventricular reciprocating tachycardia (AVRT). In AVNRT, the fast and slow pathways are located within the right atrium close to or within the AV node and exhibit electrophysiologic properties similar to AV nodal tissue. Accessory pathways that give rise to WPW syndrome and AVRT are located in the atrioventricular valvular rings. They provide a direct connection between the atria and ventricles, and have electrophysiologic properties similar to ventricular myocardium.
AV nodal reentrant tachycardia (AVNRT), or atrioventricular nodal reentrant tachycardia, is a type of tachycardia (fast rhythm) of the heart. It is a type of supraventricular tachycardia (SVT), meaning that it originates from a location within the heart above the bundle of His. AV nodal reentrant tachycardia is the most common regular supraventricular tachycardia. It is more common in women than men (approximately 75% of cases occur in females). The main symptom is palpitations. Treatment may be with specific physical maneuvers, medication, or, rarely, synchronized cardioversion. Frequent attacks may require radiofrequency ablation, in which the abnormally conducting tissue in the heart is destroyed.
AVNRT occurs when a reentry circuit forms within or just next to the atrioventricular node. The circuit usually involves two anatomical pathways: the fast pathway and the slow pathway, which are both in the right atrium. The slow pathway (which is usually targeted for ablation) is located inferior and slightly posterior to the AV node, often following the anterior margin of the coronary sinus. The fast pathway is usually located just superior and posterior to the AV node. These pathways are formed from tissue that behaves very much like the AV node, and some authors regard them as part of the AV node.
The fast and slow pathways should not be confused with the accessory pathways that give rise to Wolff-Parkinson-White syndrome (WPW syndrome) or atrioventricular reciprocating tachycardia (AVRT). In AVNRT, the fast and slow pathways are located within the right atrium close to or within the AV node and exhibit electrophysiologic properties similar to AV nodal tissue. Accessory pathways that give rise to WPW syndrome and AVRT are located in the atrioventricular valvular rings. They provide a direct connection between the atria and ventricles, and have electrophysiologic properties similar to ventricular myocardium.
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An electrocardiogram (ECG or EKG) records the electrical signal from your heart to check for different heart conditions. Electrodes are placed on your chest to record your heart's electrical signals, which cause your heart to beat. The signals are shown as waves on an attached computer monitor or printer
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5. Short RP SVT
1. Slow-Fast AVNRT:
No apparent retrograde P wave: 50%
Pseudo Rโ in V1 or pseudo-S in inferior
leads: 50% (RP<70 ms)
โข Orthodromic AVRT: 70 ms<RP<PR
The presence of delta wave in NSR.
6. AT with PR prolongation: the presence of
AV block favors AT.
8. SVT with Electrical Alternans
โข Electrical (QRS) alternans during narrow
QRS tachycardias is a rate-related
phenomenon.
โข It depends on an abrupt increase to a
critical rate.
โข It is independent of the tachycardia
mechanism.
(Morady F et al. JACC 1987)
9. Long RP SVT
1. Fast-Slow AVNRT:
Positive p wave in V1 and negative p
wave in inferior leads.
โข Are the P waves of SF and FS AVNRT
different?
4. Orthodromic AVRT using decremental
(slow) APs.
3. AT with normal PR interval.
12. PJRT
โข The arrhythmia was permanent or incessant in
23/49 cases (47%) and paroxysmal in 26/49
(53%).
โข Eight patients (16%) presented with tachycardia-
induced cardiomyopathy (TIC).
โข The accessory pathway (AP) was located in the
right posteroseptal region in 37 cases (76%) and
in atypical sites in 12 cases (24%).
โข Regression of TIC was observed in all cases
(8/8) after catheter ablation.
(Meiltz A et al. Europace 2006)
15. Favors AVNRT
1. 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)
16. AVNRT
โข Antegrade SAVN: AH jump > 50 ms
โข Continuous curve AVNRT
โข V induced SF AVNRT
โข AVNRT with retrograde eccentric activation
โข Clinically documented, non-inducible AVNRT
(Lee SH, et al. AJC 1997)
โข During 23+/-13 months of follow-up, none of the
16 patients with slow-pathway ablation had
recurrence of PSVT.
โข However, 7 of the 11 patients without ablation
had PSVT recurrence at 13+/-14 months of
follow-up. (Lin JL et al. JACC 1998)
17. Definitions
โข Retrograde FAVN: short VA, HIS earliest-A
and no decremental conduction.
โข Retrograde SAVN: long VA, CSO earliest-A
and decremental conduction.
โข V pacing: long VA interval with jump (>50 ms); A
sequence changes from HIS to CSO earliest
2. SVT: AH<HA, CSO earliest-A
โข Retrograde intermediate AVN:
Intermediate VA interval, HIS and CSO-A
simultaneously, minimal decremental conduction
โข S-I (AH>HA) or F-I (AH<HA)
(Tai CT et al. AJC 1996)
18. Continuous curve SF AVNRT
Induction of AVNRT Induction of AVNRT
18
(Tai CT et al. Circulation 1997)
19. V Pacing Induced SF AVNRT
Retrograde fast
Antegrade slow
19
Lee PC et al. J Interv Card Electrophysiol. 2005
20. SF AVNRT with eccentric A activation
20
(Ong M. et al. IJC 2007)
21. Favors AVRT
1. No decremental conduction during
pacing (except slow AP).
2. The eccentric atrial activation with short
VA interval (>70 ms)
4. VA interval increases >30 ms with
functional BBB.
24. His refractory VPC
โข 35-55 ms before the His deflection.
โข Advance the following A: AVRT
โข VPC terminate the SVT without
conducting to the atrium: rule out AT,
favors AVRT.
โข VPC from the sites other than RVA:
LV: for left side APs
RVOT: for septal APs
25. VPC reset SVT (FS AVNRT)
No advance A
VA= 140 ms VA= 250 ms
Lower common pathway
Same retrograde A sequence
26. VPC reset SVT (AVRT)
Advance A
342 342 323 378
His refractory VPC
27. VPC terminates SVT (AVRT)
Without conduction to atrium, R/O AT
His refractory VPC, R/O AVNRT
29. VOP entrains the SVT
โข VOP could not entrain SVT: AT
โข The same atrial activation sequence:
AVNRT or AVRT
The different atrial activation sequence: AT
โข The presence of lower common pathway:
AVNRT is more likely.
โข The presence of V-A-A-V response: AT
โข The presence of V-A-V response: favors
AVNRT or AVRT.
30. VOP during SVT (FS AVNRT)
A
V V
V A V AV AV A
Same retrograde A sequence
Lower common pathway
31. VOP during SVT (AT)
A A
V
V
1. The retrograde A sequence is different during tachycardia and VOP
2. The presence of V-A-A-V response during VOP
(Veenhuyzen G. et al. PACE 2011)
33. Ablation Strategy of AVNRT
โข Make a correct diagnosis!!!
โข Ablation of antegrade or retrograde slow AVN
โข Anatomic approach: P๏ M๏ A
โข Electrogram approach: ๅฐ A, ๅคง V (slow
potential)
โข Junctional tachycardia during RF
โข Mapping during V pacing but ablation during SR
(for retrograde SAVN only): ABL-earliest A
โข How to avoid AV block?
โข Ablation during A pacing
โข Avoid ablation during SVT or V pacing.
โข Quick hand! Quick leg! Quick brain! (You have
40. Ablation Strategy of AVRT
โข Make a correct diagnosis!!!
โข Localization of the APs: 12-lead ECG
algorithm and intracardiac recordings.
โข A-V or V-A fusion or earliest
โข Antegrade approach: for RT AP
โข Retrograde approach: for LT AP
6. V site (subvalvular): small A, large V, stable
ablation catheter
7. A site (ante- or retro-grade): larger A, unstable
ablation catheter
68. Small & narrow P wave๏จRA & LA depolarization simultaneously
Test 1 A P wave in the midpoint between the two QRS beats
Diagnosis: SF AVNRT with 2:1 AV block
71. Test 2
A 57 Y/O male patient had an arrhythmic attack during hospitalization.
PSVT with (RBBB) cycle length alternans and a fixed short RP interval
Cycle length alternans due to one longer and another shorter PR interval
Diagnosis: Orthodromic AVRT with dual AVN physiology
Initiation?