Complex svt with differentiation


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Complex svt with differentiation

  1. 1. Complex SVT with differentiationAdvanced Cardiac Arrhythmia Training Course ( 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 15, 2012 於台北國賓飯店
  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% (RP<70 ms)• 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.
  6. 6. S-F AVNRT Pseudo-R’Pseudo-S
  7. 7. Orthodromic AVRT RP>70 ms, electrical alternans
  8. 8. SVT with Electrical Alternans• Electrical (QRS) alternans during narrow QRS tachycardias is a rate-related phenomenon.• It depends on an abrupt increase to a critical rate.• It is independent of the tachycardia mechanism. (Morady F et al. JACC 1987)
  9. 9. Long RP SVT1. Fast-Slow AVNRT: Positive p wave in V1 and negative p wave in inferior leads.• Are the P waves of SF and FS AVNRT different?4. Orthodromic AVRT using decremental (slow) APs.3. AT with normal PR interval.
  10. 10. FS AVNRT
  11. 11. PJRT (slow AP)
  12. 12. PJRT• The arrhythmia was permanent or incessant in 23/49 cases (47%) and paroxysmal in 26/49 (53%).• Eight patients (16%) presented with tachycardia- induced cardiomyopathy (TIC).• The accessory pathway (AP) was located in the right posteroseptal region in 37 cases (76%) and in atypical sites in 12 cases (24%).• Regression of TIC was observed in all cases (8/8) after catheter ablation. (Meiltz A et al. Europace 2006)
  13. 13. AT (with AV block)
  14. 14. EP study fordifferential diagnosis of SVTs
  15. 15. 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)
  16. 16. AVNRT• Antegrade SAVN: AH jump > 50 ms• Continuous curve AVNRT• V induced SF AVNRT• AVNRT with retrograde eccentric activation• Clinically documented, non-inducible AVNRT (Lee SH, et al. AJC 1997)• During 23+/-13 months of follow-up, none of the 16 patients with slow-pathway ablation had recurrence of PSVT.• 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. 17. Definitions• Retrograde FAVN: short VA, HIS earliest-A and no decremental conduction.• Retrograde SAVN: long VA, CSO earliest-A and decremental conduction.• V pacing: long VA interval with jump (>50 ms); A sequence changes from HIS to CSO earliest2. SVT: AH<HA, CSO earliest-A• Retrograde intermediate AVN: Intermediate VA interval, HIS and CSO-A simultaneously, minimal decremental conduction• S-I (AH>HA) or F-I (AH<HA) (Tai CT et al. AJC 1996)
  18. 18. Continuous curve SF AVNRT Induction of AVNRT Induction of AVNRT 18 (Tai CT et al. Circulation 1997)
  19. 19. V Pacing Induced SF AVNRT Retrograde fast Antegrade slow 19 Lee PC et al. J Interv Card Electrophysiol. 2005
  20. 20. SF AVNRT with eccentric A activation 20 (Ong M. et al. IJC 2007)
  21. 21. Favors AVRT1. 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.
  22. 22. LT AP with LBBB (Josephson ME. P237)
  23. 23. Single VPC reset SVT
  24. 24. His refractory VPC• 35-55 ms before the His deflection.• Advance the following A: AVRT• VPC terminate the SVT without conducting to the atrium: rule out AT, favors AVRT.• VPC from the sites other than RVA: LV: for left side APs RVOT: for septal APs
  25. 25. VPC reset SVT (FS AVNRT) No advance A VA= 140 ms VA= 250 ms Lower common pathway Same retrograde A sequence
  26. 26. VPC reset SVT (AVRT) Advance A 342 342 323 378 His refractory VPC
  27. 27. VPC terminates SVT (AVRT) Without conduction to atrium, R/O AT His refractory VPC, R/O AVNRT
  28. 28. Ventricular Overdrive Pacing (VOP) (10-40 msshorter than tachycardia) during SVT
  29. 29. 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.
  30. 30. VOP during SVT (FS AVNRT) A V V V A V AV AV A Same retrograde A sequence Lower common pathway
  31. 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)
  32. 32. (Veenhuyzen G. et al. PACE 2011)
  33. 33. Ablation Strategy of AVNRT• Make a correct diagnosis!!!• Ablation of antegrade or retrograde slow AVN• Anatomic approach: PMA• Electrogram approach: 小 A, 大 V (slow potential)• Junctional tachycardia during RF• Mapping during V pacing but ablation during SR (for retrograde SAVN only): ABL-earliest A• How to avoid AV block?• Ablation during A pacing• Avoid ablation during SVT or V pacing.• Quick hand! Quick leg! Quick brain! (You have
  34. 34. Slow Potential 34
  35. 35. JT during ablation True Junctional rhythm H H CS junctional rhythm 35
  36. 36. Transient complete AVB Complete AVB One second 36
  37. 37. Transient complete AVB Complete AVB for more than 10 seconds 37
  38. 38. SAVN Ablation SiteRAO 30 degree LAO 60 degree 38
  39. 39. Ablation site RAO 30 degree LAO 60 degreeRetrogradeSlow AVNAntegradeSlow AVN
  40. 40. Ablation Strategy of AVRT• Make a correct diagnosis!!!• Localization of the APs: 12-lead ECG algorithm and intracardiac recordings.• A-V or V-A fusion or earliest• Antegrade approach: for RT AP• Retrograde approach: for LT AP6. V site (subvalvular): small A, large V, stable ablation catheter7. A site (ante- or retro-grade): larger A, unstable ablation catheter
  41. 41. Delta Wave in NSR (Chiang CE et al. AJC 1996)
  42. 42. Cases Discussion
  43. 43. Case 1: 12 lead ECG Long RP tachycardia
  44. 44. RAS1S2 induced PSVT A H A CSO-A earliest FS AVNRT? Orthodromic AVRT? Or AT
  45. 45. VPC reset SVT No advance the following AThe same retrograde A sequence Increased the VA interval
  46. 46. VOP during SVT: A A V V 1. The same atrial activation sequence 2. Progressive prolongation of VA interval 3. The presence of V-A-A-V response
  47. 47. VOP changes SVT FS AVNRT SF AVNRT
  48. 48. Another SVT SF AVNRT
  49. 49. Successful ablation site
  50. 50. JT during RF
  51. 51. PR prolongation during RF
  52. 52. VA dissociation after Ablation
  53. 53. Successful ablation site
  54. 54. Case 2: 12 lead ECG RP>70 ms
  55. 55. RVS1S1 350 ms His-A earliest CS ostium at 5,6?
  56. 56. RAS1S1 550 ms
  57. 57. RAS1S1+isuprel induced PSVT A H A CS9,10-A earliest AH~=HA
  58. 58. PSVT
  59. 59. VPC terminates SVT AT is not likely
  60. 60. RVS1S1 350 ms+ isuprel Increased VA interval Fusion FAVN
  61. 61. VPC Reset SVT No advance A
  62. 62. VOP during SVT No decremental conduction
  63. 63. VPC reset SVT VPC advance A
  64. 64. Successful ablation site
  65. 65. Successful ablation
  66. 66. Successful ablation siteRAO LAO
  67. 67. Unknown Tracings
  68. 68. Small & narrow P waveRA & LA depolarization simultaneouslyTest 1 A P wave in the midpoint between the two QRS beats Diagnosis: SF AVNRT with 2:1 AV block
  69. 69. Test 1AT with 2:1 AV block?What’s the next step?
  70. 70. Test 1: VOP 2:1 to 1:1 conduction
  71. 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 physiologyInitiation?
  72. 72. Test 2:RAS1S2 500/380 ms One P with three Q 1. FAVN 2. SAVN 3. AVRT echo
  73. 73. Test 2: Spontaneous Initiation of SVT One P with Two Q Orthodromic AVRT with antegrade FAVN and retrograde LL AP
  74. 74. 謝謝聆聽敬請指教