A novel approach to differentiating orthodromic reciprocating tachycardia from atrioventricular nodal reentrant tachycardia

Dandamudi, Gopi; Mokabberi, Rasoul; Assal, Chafik; Das, Mithilesh K.; Oren, Jess W.; Storm, Randle; Vijayaraman, Pugazhendhi; Miller, John M.

doi:10.1016/j.hrthm.2010.05.033

Cited by 77 publications

(59 citation statements)

References 8 publications

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“…In such situations, evaluating the response of tachycardia at the beginning of ventricular overdrive pacing can help differentiate ORT from AVNRT but does not distinguish NFRT from PJRT or AVNRT/NF AP from ORT. 21,22 Atrial extrastimulation and overdrive pacing were not systematically performed during tachycardia to exclude junctional tachycardia or assess VA linking. [23][24][25] However, because focal junctional tachycardia associated with retrograde conduction over the SP is extremely rare and none of our tachycardias exhibited nonreentrant behavior (eg, warm-up/cool-down phenomena, initiation after a spontaneous junctional complex), we are confident of our diagnoses.…”

Section: Limitationsmentioning

confidence: 99%

Electrophysiological Features Differentiating the Atypical Atrioventricular Node–Dependent Long RP Supraventricular Tachycardias

Frisch

Pavri

et al. 2013

Circ: Arrhythmia and Electrophysiology

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E stablishing the diagnosis of an atypical atrioventricular (AV) node-dependent long RP supraventricular tachycardia (SVT) can be difficult. Standard diagnostic criteria are lacking and often extrapolated from pacing maneuvers applied to the more common short RP SVT. Long RP SVTs involving concealed nodofascicular (NF) accessory pathways (AP) are particularly rare with descriptions limited to isolated case reports. [1][2][3][4] Prolonged conduction over the slow pathway (SP) of the AV node or a decremental AP after entrainment from the ventricle can produce A-A-V patterns that might be mistaken for atrial tachycardia (AT). 5 In addition, slow AP conduction after entrainment of an atypical orthodromic reciprocating tachycardia (ORT) can generate long postpacing intervals (PPI) that cause misdiagnosis of AV nodal reentrant tachycardia (AVNRT), despite correction for delay in the AV node (cPPI). [5][6][7] This study sought to evaluate the electrophysiological features and criteria differentiating the 4 atypical AV node-dependent long RP SVTs: atypical AVNRT, atypical AVNRT with a concealed, bystander NF AP (atypical AVNRT/NF AP), ORT using a concealed, slowly conducting, decremental AV AP (also called the permanent form of junctional reciprocating tachycardia [PJRT]), and ORT using a concealed NF AP (also called NF reentrant tachycardia [NFRT]

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Section: Limitationsmentioning

confidence: 99%

Electrophysiological Features Differentiating the Atypical Atrioventricular Node–Dependent Long RP Supraventricular Tachycardias

Frisch

Pavri

et al. 2013

Circ: Arrhythmia and Electrophysiology

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“…Another stems from the older discussion about the atrioventricular node final common pathway, which would be responsible for the delayed entrainment. 6,7 In contrast, SVE advancement preceding atrial reset was rarely observed during AVRT mediated by anteroseptal, parahisian, and midseptal APs, thus reflecting the association between the high ventricular septum and the tachycardia mechanism. Only 2 cases revealed the unexpected phenomena during one single cycle.…”

Section: Rationale Of the Study And Mechanismmentioning

confidence: 99%

“…Also, Dandamudi et al described that the time-dependent pattern of resetting the atrium by RVA pacing yielded appropriate diagnostic discrimination even if the tachycardia mechanism was interrupted. 7 Here we describe a complementary diagnostic method based on the differential timing between the septal ventricular electrogram (SVE) and the atrial signals during continuous ventricular pacing from the RVA. We analyzed the responses in the clinical scenario of 2 tachycardia mechanisms that require extensive electrophysiological investigation, atypical AVNRT, and atrioventricular reentrant tachycardia (AVRT) mediated by septal AP.…”

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confidence: 99%

Differential Responses of the Septal Ventricle and the Atrial Signals During Ongoing Entrainment

Calvo

Ávila

García-Fernández

et al. 2015

Circ: Arrhythmia and Electrophysiology

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S eptal accessory pathways (APs) and atypical atrioventricular nodal reentry (AVNRT) commonly mediate supraventricular tachycardia with concentric atrial activation and long ventriculoatrial (VA) intervals. Several diagnostic maneuvers can aid differential diagnosis, including a return cycle after continuous entrainment from the right ventricular apex (RVA), 1,2 tachycardia resetting with electrocardiographic fusion, 3,4 and even responses to single ventricular extrastimulus.5 However, it has been reported that ≤15% to 20% of the tachycardia mechanism could be interrupted by the entrainment maneuvers. 5 In these instances, the utility of RVA pacing during tachycardia at the beginning of the entrainment attempt has received less attention as a diagnostic technique. Recently, AlMahameed et al elegantly © 2015 American Heart Association, Inc. ). SVE advancement preceding atrial reset was observed in 98% of atrioventricular nodal reentries during 4±1.1 cycles; this phenomena was observed in 6 (8%) of the atrioventricular reentrant tachycardia mediated by septal AP (P<0.001; sensitivity 98%; specificity 93%; positive predictive value 90%; negative predictive value 99%) and lasted 1 single cycle (P<0.001). Right posteroseptal AP tachycardias were distinctly characterized by atrial reset preceding SVE advancement (with ventricular fusion; specificity 100%; positive predictive value 100%). In 11 cases, it was impossible to achieve sustain entrainment. In all of them, the differential responses at the entrainment attempt allowed for appropriate diagnosis. Conclusions-The differential response of the SVE and the atrial electrogram at the initiation of continuous right ventricular apical pacing during tachycardia effectively distinguishes between atypical atrioventricular nodal reentry and atrioventricular reentrant tachycardia mediated by septal APs. (Circ Arrhythm Electrophysiol. Circ Arrhythm Electrophysiol

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“…Usually, a combined anatomical and mapping approach is employed with ablation lesions delivered at the inferior or mid part of the triangle of Koch. 60,61 Multicomponent atrial electrograms or low amplitude potentials, although not specific for identification of slow pathway -SA-VA and cPPI-TCL intervals [44][45][46][47] -Differential entrainment or cessation 48 Cumbersome Delta HA during V Pre-excitation index 49 Differential entrainment 58 pacing and tachycardia 36 Entrainment VHA pattern 37 -Anterograde His capture 50 Para-Hisian pacing 38 -Progressive fusion during or after the transition zone 51,52 Induction of retrograde Delta HA during entrainment RBBB 39 and tachycardia 53 SA init -VA and cPPI init --Para-Hisian entrainment [54][55][56] TCL conduction, are successfully used to guide ablation at these areas.…”

Section: Ablationmentioning

confidence: 99%

Classification, Electrophysiological Features and Therapy of Atrioventricular Nodal Reentrant Tachycardia

Katritsis

Josephson

2016

Arrhythmia &Amp; Electrophysiology Review

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Atrioventricular nodal reentrant tachycardia (AVNRT) denotes re-entry in the area of the AV node, and represents the most common regular arrhythmia in the human.1 Although several models have been proposed to explain the mechanism of the arrhythmia in the context of the complex anatomy and the anisotropic properties of the atrioventricular (AV) node and its atrial extensions (see Figure 1), 2 the actual circuit of AVNRT still remains elusive. Recent studies suggest a three-dimensional AV node with greater variability in the space constant of tissue and poor gap junction connectivity due to differential expression of connexin isoforms, that provide an explanation of dual conduction and nodal reentrant arrhythmogenesis. 3,4 AV junctional arrhythmias are presented in Table 1. Classification schemes for AVNRT have been mainly based on the conventional concept of longitudinally dissociated dual AV nodal pathways that conduct around a central obstacle (see Table 2).In typical slow-fast AVNRT the onset of atrial activation appears prior to, at the onset, or just after the QRS complex, thus maintaining an atrial-His/His-atrial ratio, AH/HA >1. The HA interval is usually <70 ms, measured from earliest deflection of the His bundle activation to the earliest rapid deflection of the atrial activation in the His bundle electrogram, and the VA interval, measured from the onset of ventricular activation on surface ECG to the earliest rapid deflection of the atrial activation on the His bundle electrogram, is <60 ms. 1,5,6 In atypical, fast-slow form of atypical AVNRT, the retrograde atrial electrogram begins after ventricular activation with an AH/HA ratio <1. The HA interval is prolonged, ≥70 msec, and the VA interval is ≥60 msec. 5,6 The atypical, slow-slow form, represents, by definition, an arrhythmia utilising two slow pathways. The AH/HA ratio is ≥1 but the HA interval is ≥70 msec, and the AH interval exceeds 200 ms. [7][8][9] There are several inherent limitations of this classification. The distinction between fast-slow and slow-slow atypical AVNRT is often arbitrary in view of the lack of a unanimously accepted definition. In order to establish the diagnosis of a truly fast-slow form, it has been proposed that the AH interval should be less than 185 ms 10 or 200 ms. 6 This criterion, however, has not been adopted by other investigators. 11-13Thus, tachycardias with a relatively prolonged AH interval but an AH/ HA ratio <1 cannot be reliably classified as either fast-slow or slow-slow (see Figure 2). Furthermore, the term 'fast-slow' implies that the fast component of slow-fast AVNRT is the same as the fast in the fast-slow type. There is now evidence that this is not the case in patients who present with both types of tachycardia.14,15 Typical slow-fast and atypical fast-slow AVNRT appear to utilise different anatomical pathways for fast conduction. In addition, electrophysiological behaviour compatible with multiple pathways may also be seen, and in some patients, several forms of AVNRT may be inducible at electrophy...

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A novel approach to differentiating orthodromic reciprocating tachycardia from atrioventricular nodal reentrant tachycardia

Cited by 77 publications

References 8 publications

Electrophysiological Features Differentiating the Atypical Atrioventricular Node–Dependent Long RP Supraventricular Tachycardias

Electrophysiological Features Differentiating the Atypical Atrioventricular Node–Dependent Long RP Supraventricular Tachycardias

Differential Responses of the Septal Ventricle and the Atrial Signals During Ongoing Entrainment

Classification, Electrophysiological Features and Therapy of Atrioventricular Nodal Reentrant Tachycardia

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