Ventricular fusion during resetting and entrainment of orthodromic supraventricular tachycardia involving septal accessory pathways. Implications for the differential diagnosis with atrioventricular nodal reentry.

Ormaetxe, José; Almendral, Jesús; Arenal, Ángel; Martı́nez-Alday, Jesús; Pastor, A. García; Pérez-Villacastín, Julián; Delcán, Juan L.

doi:10.1161/01.cir.88.6.2623

Cited by 53 publications

(59 citation statements)

References 28 publications

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“…The use of tachycardia entrainment via ventricular pacing for differential diagnosis of supraventricular tachycardias was introduced by Ormaetxe et al 34 Right apical stimulation is relatively close to the insertion of a septal accessory pathway as opposed to the AV junction; thus, ventricular fusion during resetting or entrainment of tachycardia has been reported to occur in patients with AVRT due to septal pathways but not with AVNRT. 34 Michaud et al 35 have proposed 2 additional criteria for differential diagnosis.…”

Section: Tachycardia Entrainmentmentioning

confidence: 99%

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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%

“…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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“…These factors make the differential diagnosis challenging. [8][9][10] Electrical stimulation is widely used in electrophysiology. [11][12][13] His bundle refractory period pacing is used to differentiate AVNRT from ORT.…”

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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“…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.…”

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confidence: 99%

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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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Ventricular fusion during resetting and entrainment of orthodromic supraventricular tachycardia involving septal accessory pathways. Implications for the differential diagnosis with atrioventricular nodal reentry.

Cited by 53 publications

References 28 publications

Atrioventricular Nodal Reentrant Tachycardia

Atrioventricular Nodal Reentrant Tachycardia

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

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

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