Differentiation of atypical atrioventricular node re-entrant tachycardia from orthodromic reciprocating tachycardia using a septal accessory pathway by the response to ventricular pacing

Michaud, Gregory F.; Tada, Hiroshi; Chough, Steven P.; Baker, Robert L.; Wasmer, Kristina; Sticherling, Christian; Oral, Hakan; Pelosi, Frank; Knight, Bradley P.; Strickberger, S. Adam; Morady, Fred

doi:10.1016/s0735-1097(01)01480-2

Cited by 246 publications

(197 citation statements)

References 11 publications

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“…34 Michaud et al 35 have proposed 2 additional criteria for differential diagnosis. The ventriculoatrial (VA) interval and tachycardia cycle length (TCL) were measured during tachycardia, and entrainment of the tachycardia was accomplished with RV apical pacing.…”

Section: Tachycardia Entrainmentmentioning

confidence: 99%

Atrioventricular Nodal Reentrant Tachycardia

2010

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A trioventricular nodal reentrant tachycardia (AVNRT) represents the most common regular supraventricular arrhythmia in humans. 1 The precise anatomic site and nature of the pathways involved have not yet been established, and several attempts to provide a reasonable hypothesis based on anatomic or anisotropic models have been made. 2 There has been considerable evidence that the right and left inferior extensions of the human atrioventricular (AV) node and the atrionodal inputs they facilitate may provide the anatomic substrate of the slow pathway, and a comprehensive model of the tachycardia circuit for all forms of AVNRT based on the concept of atrionodal inputs has been proposed. 2 Still, however, the circuit of AVNRT remains elusive. Recently, time-honored conventional schemes for the diagnosis and classification of the various forms of the arrhythmia have been refuted in part by evolving evidence. Recognition of the various types of AVNRT is important, however, to expedite diagnosis and allow implementation of appropriate ablation therapy without complications. We present an update on AVNRT with a particular emphasis on electrophysiological criteria used for the differential diagnosis of regular, supraventricular tachycardias. ECG PresentationTypically, AVNRT is a narrow-complex tachycardia, ie, QRS duration Ͻ120 ms, unless aberrant conduction, which is usually of the right bundle-branch type, or a previous conduction defect exists. Tachycardia-related ST depression and RR-interval variation may be seen. RR alternans in AVNRT has been attributed to the proposed model of a figure of 8 reentry with continuous crossing over of antegrade activation through an inferior input to the contralateral superior input via the node. 2 In the typical form of AVNRT (slow-fast), abnormal (retrograde) PЈ waves are constantly related to the QRS and in the majority of cases are indiscernible or very close to the QRS complex (RPЈ/RR Ͻ0.5). Thus, PЈ waves are either masked by the QRS complex or seen as a small terminal PЈ wave that is not present during sinus rhythm (Figure 1). In the atypical form of AVNRT (fast-slow), PЈ waves are clearly visible before the QRS, ie, RPЈ/PЈR Ͼ0.75 (Figure 2), denoting a "long RP tachycardia," and are negative in leads II, III, aVF, and V 6 but positive in V 1 . PЈ waves are shallow in the inferior leads in the rare form of anterior fast-slow AVNRT. 3 Although AV dissociation is usually not seen, it can occur because neither the atria or the ventricles are necessary for the reentry circuit. If the tachycardia is initiated by atrial ectopic beats, the initial (ectopic) PЈ wave usually differs from the subsequent (retrograde) PЈ waves (Figure 1).

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Section: Tachycardia Entrainmentmentioning

confidence: 99%

Atrioventricular Nodal Reentrant Tachycardia

2010

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“…Other studies: Premature right ventricular complexes pacing 14) and entrainment pacing for differentiating AVNRT from ORT has been reported in previous studies. [15][16][17][18] Michaud, et al 15) reported that the postpacing interval after entrainment of AVNRT by RV pacing exceeded the tachycardia cycle length by > 115 ms. Their method is often used to identify the septal AP. However, for left side AP, there may be some limitations.…”

Section: Discussionmentioning

confidence: 99%

A Simple Method to Differentiate Atrioventricular Node Reentrant Tachycardia from Orthodromic Reciprocating Tachycardia

Lei

Jia

et al. 2018

Int. Heart J.

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SummaryDiscrimination between atrioventricular node reentry tachycardia (AVNRT) and orthodromic reciprocating tachycardia (ORT) during an electrophysiological study is sometimes challenging. This study aimed to investigate if the difference in the local VA (ventricle-atrium) interval during ventricular entrainment pacing and during tachycardia (DVA, defined as the shortest local VA interval of coronary sinus [CS] during entrainment minus the shortest local VA interval of CS during tachycardia) was different in patients with AVNRT and patients with ORT.Diagnoses of AVNRT or ORT through a concealed accessory pathway (AP) were made according to conventional electrophysiological criteria and ablation results. Entrainment by right ventricular (RV) pacing was performed in each patient before ablation and patients with successful entrainment were included in the study. The DVA was compared between patients with AVNRT and patients with ORT. The DVA in patients with AVNRT was significantly longer than that in patients with ORT (120 ± 20 versus 5.7 ± 9; P < 0.001). In each patient with AVNRT of slow-fast type, fast-slow type, and slow-slow type, the DVA was more than 48 ms. In each patient with ORT using a left free wall accessory pathway (AP), right free wall AP, and septal AP, the DVA was less than 20 ms.DVA was found to be a rapid, useful test in distinguishing patients with AVNRT from those with ORT.(Int Heart J 2018; 59: 71-76) Key words: Mechanism, Electrophysiological examination, Ventricular entrainment pacing D iscrimination between atrioventricular node reentry (AVNRT) and orthodromic reciprocating tachycardia (ORT) during an electrophysiological study can be occasionally challenging. [1][2][3][4][5] Since the local ventricle and local atrium near the accessory pathway (AP) are components of ORT 6) and they are activated sequentially during entrainment and during tachycardia, the local ventricle-atrium (VA) interval near the AP during ventricular entrainment pacing of the tachycardia may be similar to the local VA interval near the AP during tachycardia. On the other hand, it has been established that the ventricle does not contain the component of the circuit of AVNRT,6) and therefore the local VA interval during entrainment may be different from that during tachycardia.Because almost all APs (except for the Mahaim bundle) were located in the mitral annulus or tricuspid annulus, we assumed the shortest local VA interval of the coronary sinus (CS) was the local VA interval when the AP was on the left side or in a septal location. For AVNRT, the local VA interval during entrainment of the tachycardia and that during the tachycardia should be different because the activation pattern during entrainment is different from that during tachycardia. When it comes to a right side AP, we aimed to investigate if there were properties of the local VA interval of the CS orifice using the right AP that could be used to differentiate ORT from AVNRT.In this study, we tested the value of a new parameter: the shortest VA interval...

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“…5 A postpacing interval-tachycardia CL (PPI-TCL) > 115 ms is usually consistent with AVNRT, while a PPI-TCL difference < 115 ms is consistent with AVRT. 6 Nevertheless, a PPI-TCL > 110 ms can occur with AVRT circuited by a left-sided AP, because the right ventricular pacing site is far from such a circuit. During a long RP interval SVT, a corrected PPI-TCL > 110 ms should also prompt the consideration of orthodromic AVRT employing an AP with delayed retrograde conduction.…”

Section: Incessant Tachycardia-induced Cardiomyopathy In a Childmentioning

confidence: 99%

An Uncommon Case of Incessant Tachycardiainduced Cardiomyopathy in a Child

Poghosyan

Danoyan

Hovakimyan

et al. 2017

J Innov Cardiac Rhythm Manage

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An AXIOM Sensis XP system (Siemens AG, Munich, Germany) was also used during the procedure.Narrow complex tachycardia with a cycle length (CL) of 360 ms was ongoing. The earliest atrial activations were recorded in the left posterolateral wall (ie, at 4 o'clock according to the clinical standard nomenclature by Cosio) with the shortest ventriculoatrial (VA) interval equal to 104 ms. Few sinus complexes were recorded with concentric ventricular activation (Figure 2A). The atrium to His (AH) and His to ventricle intervals were 94 ms and 50 ms, respectively ( Figure 2B). The post-pacing interval was 492 ms with a ventricle-atrium-ventricle (VAV) response during overdrive pacing and entrainment of tachycardia from the right ventricle ( Figure 2C). Ventricular pacing within 40 ms of the His potential advanced the atrium and the atrial activation sequence to the same as that seen during tachycardia ( Figure 2D). The ventricular pacing given earlier terminated the tachycardia without advancing to the atrium ( Figure 2E). The VA interval was not decremental, although the tachycardia CL fluctuated from 310 ms to 360 ms. Because of the incessant tachycardia, we could not pace the atrium in sinus rhythm; however, the short attempts showed that the AH intervals during the sinus complexes and the atrial pacing in tachycardia CL were similar. Orthodromic atrioventricular reentrant tachycardia (AVRT) with concealed slow conductive accessory pathway (AP) was diagnosed. Case presentationA nine-year-old girl was admitted to our clinic having presented with palpitation, dyspnea, and heart failure (New York Heart Association functional classification class II). A 12-lead resting electrocardiogram (ECG) revealed regular narrow complex tachycardia (Figure 1). Echocardiography revealed reduced left ventricular systolic function (ejection fraction was 35%) and normal biatrial diameter. Tachycardia was incessant, lasting more than 50% of monitoring time prior to drug administration. Intravenous adenosine and b-blocker medication were ineffective. The patient was referred for electrophysiology (EP) study and catheter ablation. The procedure was performed with the patient under sedation with intubation. A steerable decapolar catheter (Abbott Laboratories, Chicago, IL, USA) was inserted into the coronary sinus via the subclavian vein, a quadripolar catheter (Abbott Laboratories, Chicago, IL, USA) was positioned in the right ventricle, and an ablation catheter (Marinr ® MC; Medtronic, Minneapolis, MN, USA) was placed in the His position via the right femoral vein during the EP study.ABSTRACT. The case of a pediatric patient with a history of incessant narrow complex tachycardia is presented. The patient underwent successful catheter ablation for an uncommon concealed slow accessory pathway. The mechanism and ablation location are discussed.

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Differentiation of atypical atrioventricular node re-entrant tachycardia from orthodromic reciprocating tachycardia using a septal accessory pathway by the response to ventricular pacing

Abstract: The S-A-VA interval and PPI-TCL are useful in distinguishing atypical AVNRT from ORT using a septal accessory pathway.

Cited by 246 publications

References 11 publications

Atrioventricular Nodal Reentrant Tachycardia

Atrioventricular Nodal Reentrant Tachycardia

A Simple Method to Differentiate Atrioventricular Node Reentrant Tachycardia from Orthodromic Reciprocating Tachycardia

An Uncommon Case of Incessant Tachycardiainduced Cardiomyopathy in a Child

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