different kinds of vt and differential of broad complex tachyarrythmias

1. An Introduction to
Dr Jai kumar

2. PVC/VPC/PVB/Ventricle
Extrasystole
 Premature impulse originating from ventricles
that occurs earlier than next expected normal
sinus rhythm.
 Not preceded by P wave
 QRS wide ≥ 0.12 sec
 Followed by pause usually fully compensatory

3. Multifocal pvc
Interpolated pvc
R on T phenomenon

4. End diastolic pvc
PVC in bigeminy
PVC in trigeminy or couplet
PVC in quadrigeminy

5. Origin of PVC
Right ventricle Left ventricle
Morphology of V1
LBBB RBBB
Apex Out Flow In Flow
Inferoposterior
anterosuperior
LAD
RAD
Normal
LAD
RAD

6. Classification of ventricular
arrhythmia
 Clinical – hemodynamic stable
- hemodynamic unstable
 Electrocardiographical
 Non sustained VT- Monomorphic or Polymorphic
 Sustain VT- Monomorphic or Polymorphic
 Bundle branch reentrant tachycardia
 Bidirectional VT
 Torsades de points
 Ventricular flutter
 Ventricular fibrillation

7. Ventricular tachycardia
 3 or more consecutive PVC with rate > 100/ min
 Non sustain if lasting < 30 sec
 Sustain if lasting > 30 sec or
< 30 sec but associated with hemodynamic
compromise

8. Bundle branch reentrant
tachycardia
 VT is due to Reentry
 Rt ventricle Septum Lt ventricle
 During NSR baseline ECG shows incomplete
or complete LBBB
 May respond to radiofrequency ablation

9. Bidirectional tachycardia
 VT originates from two separate locations
1. Left anterior fascicles & 2. left posterior fascicles
RBBB + Right Axis RBBB + Left Axis
 Axis alternate between right and left axis in frontal
plane
 Frequently associated with digitalis toxicity

10. Torsades de Pointes
 Polymorphic VT associated with prolonged QTc interval
 QTc prolonged if > 0.44 sec in men
> 0.46 sec in women and
children
 Pause dependent occurring when there is bradycardia.
 Frequently seen in setting of long and short cycles

11. Ventricular Flutter
 Similar to monomorphic VT with rate > 250/min
 No isoelectric interval between QRS complex.
Ventricular Fibrillation
 Disorganised ventricular rhythm with poorly
defined QRS.
 Rate > 300/min

12. Wide Complex Tachycardia
 VT
 SVT with
○ Preexistent BBB
○ Antidromic AVRT
○ Ventricular Aberration or rate related BBB

13. VT v/s SVT
If single rhythm strip available
 Unusally wide QRS
 Complete AV dissociation.

14. •Presence of ventricle fusion complex.

15.  Sinus captured complex or Dressler complex
 Ventriculoatrial conduction with block.

16. In 12 lead ECG
 Brugada Algorithm
 Vereckei algorithm
 aVR Vereckei Algorithm
 Lead II R wave peak time RWPT

18. Brugada Algorithm
Absence of an RS complex
in all precordial leads?
R to S interval > 100ms in
one precordial lead ?
Morphology criteria for VT
present in precordial leads
V1-2 and V6 ?
A V dissociation ?
SVT
VT
VT
VT
VT
No
No
No
No
Yes
Yes
Yes
Yes

23. 4 a. LBBB morphology: Dominant S wave in V1 or V2
 Lead V1 or V2
 R Wave duration ≥ 0.04 sec
 RS duration ≥ 0.07 sec
 Slurring or notching of S wave (Josephson Sign)
 Lead V 6
 Any q wave

24. 4 b. RBBB morphology: Dominant R wave in V1 or V2
 Lead V1
 Monophasic R wave
 Biphasic QRS complex ( qR ,Rs)
 Lead V 6
 Any QS complex
 R/S ratio < 1 means R smaller than S

26. Vereckei Algorithm
AV dissociation present ?
Initial R wave in aVR
Present ?
Vi/Vt ≤ 1 ?
QRS morphology unlike BBB
of FB ?
SVT
VT
VT
VT
VT
No
No
No
No
Yes
Yes
Yes
Yes

27. aVR criteria
1. Presence of initial R wave in aVR.
2. Presence of initial r or q wave of > 0.40 sec
3. Nothching of initial downstroke of a
predominantly negative QRS
If any of three present its VT, when absent 4th
criteria is analysed
4. Ventricular activation velocity ratio Vi/Vt ≤ 1

28. aVR criteria
1
2
3

29. Lead II R Wave Peak Time
Criteria
 Time of intrinsicoid deflection measured
in lead II i.e onset of peak of first
positive or negative deflection.

30. Other findings for d/g of VT
 1. RBBB morphology with LAD> -30
 2. LBBB morphology with RAD > +90
 3. Northwest Axis
 4. Concordance QRS complex
 5. Rabbit ear

31. ACC/AHA/ESC
Guideline

32. Treatment of Ventricular Fibrillation
 DC Cardioversion
 Precordial thump
 CPR
 Pharmacologic agents
 Epinephrine 1mg stat repeated 3-5 min
 Amiodarone 300 mg stat 1.0mg/min for 6 hr
Follwed by 0.5mg/min for next 18 hr.

33. Treatment of Sustain Monomorphic VT
 Unstable patient: synchronised cardioversion.
 Stable patient with EF > 40%
 Procainamide 17mg /kg loading f/b maintenance 1-
4mg/min
 Amiodarone 150mg bolus f/b infusion 1mg/min for 6 hr
0.05mg/min for 18 hr
 Lidocaine 1mg/kg bolus f/b maintenance 1-4 mg/min
Treatment of Sustain Polymorphic VT
 Mostly unstable DC Cardioversion f/b pharmacotherapy
depending on Qtc interval
 Regular PVT- usually a/w myocardial ischemia, AAD similar to
monomorphic VT

34. Thank you