AVNRT VS AVRT

5/20/2018 AVNRT VS AVRT

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Advanced AVNRT and AVRT

With differentiationAdvanced EP Training()

April 24, 2011


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Etiology: ( )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% orslow AP 10%)

3. AT (n=245): 8%

Supraventricular tachycardia (SVT)


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12-lead ECG for

differential diagnosisof SVTs (important!)


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Retrograde P wave in SVT

(Tai CT et al. JACC 1997)


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Short RP SVT

1. Slow-Fast AVNRT:

No apparent retrograde P wave: 50%Pseudo R in V1 or pseudo-S in inferiorleads: 50%

2. Orthodromic AVRT: 70 ms


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S-F AVNRTPseudo-R

Pseudo-S


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NSR after IV adenosineNo pseudo-R and pseudo-S


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S-F AVNRTNo apparent P wave


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S-F AVNRTP wave masked by QRS


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S-F AVNRTPseudo-R and pseudo-S


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S-F AVNRTPseudo-R and pseudo-S


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Orthodromic AVRTRP>70 ms, favor LL AP


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MWPW (LL or LAL AP)


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Long RP SVT

1. Fast-Slow AVNRT:

Positive p wave in V1 and negative pwave in inferior leads.

2. Orthodromic AVRT using decremental(slow) APs.

3. AT with normal PR interval.


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EP study for

differential diagnosisof SVTs


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Favors AVNRT

1. 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-Vor A before V (SF AVNRT)


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AVNRT

Antegrade SAVN: AH jump > 50 ms

Continuous curve AVNRT

Retrograde SAVN:

1.Long VA interval

2.CSO-A earliest.

Retrograde intermediate AVN:

1.Intermediate VA interval2.His-A and CSO-A both earlier

AVNRT with retrograde eccentricactivation


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Continuous curve AVNRT

(Tai CT et al. Circulation 1997)


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Initiation of S-F AVNRTProgressive AH prolongation with jump


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Lower common pathway

V V V VA A A A

Progressive prolongation of VA interval


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AVNRT with eccentric A activation

(Ong M. et al. IJC 2007)


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Favors AVRT

1. No decremental conduction during

pacing (except slow AP).2. The eccentric atrial activation with short

VA interval (>70 ms)3. VA interval increases >30 ms with

functional BBB.


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LT AP with LBBB

(Josephson ME. P237)


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Single VPC reset SVT


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His refractory VPC

35-55 ms before the His deflection.

Advance the following A:AVRT

VPC without conducting to atrium but

terminate the SVT: rule out AT. VPC from the sites other than RVA:

LV: for left side APsRVOT: for septal APs


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Ventricular Overdrive

Pacing (VOP) (10-40 ms

shorter than tachycardia)during SVT


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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.


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VOP during SVT

(Veenhuyzen G. et al. PACE 2011)

1. The retrograde A sequence is different during tachycardia and VOP

2. The presence of V-A-A-V response during VOP

AT

V

A A

V


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Hirao, K. et al. Circulation 1996;94:1027-1035

Para-Hisian pacing


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Ablation Strategy of AVNRT

Make a correct diagnosis!!!

Ablation of slow or intermediate AVN

1. Anatomic approach: PMA

2. Electrogram approach: small A, large V

3. JT during RF

How to avoid AV block?

1. ablation during A pacing2. avoid ablation during SVT or V pacing.

3. You have only one second to stop RF!!!


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JT under during RF


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Transient second degree AVB


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Flat and horizontal Kochs Triangle

(Lee PC et al. Curr Opin Cardiol. 2009)

RAO LAO


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Ablation Strategy of AVRT

Make a correct diagnosis!!!

Localization of the APs: 12-lead ECGalgorithm and intracardiac recordings.

Antegrade approach: for RT AP

Retrograde approach: for LT AP

1. V site (subvalvular): small A, large V, stable

ablation catheter2. A site (ante- or retro-grade): larger A, unstable

ablation catheter


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Delta Wave in NSR

(Chiang CE et al. AJC 1996)


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Whats on the other side


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Cases Discussion


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Case 1VT, PSVT with RBBB or preexcitated tachycardia?


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RA burst + Isuprel induce SVT

AVNRT with Wenkebach AV block then 1:1 conduction

Whats the mechanism of SVT?


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S-F AVNRT


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PSVT with LBBB

RVS1S2 i d d PSVT


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RVS1S2 induced PSVT

500 270


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Retrograde-intermediate AVN or AP?

AH=188 ms HA=158 ms


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VPC terminate SVT: AVN or AP?

347 ms 347 ms 293 ms


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V pacing during SVT: AVN or AP?

350 ms

372 ms

Lower common pathway

Mapping retrograde pathway and terminate


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Mapping retrograde pathway and terminate

SVT (after ablation of antegrade SAVN)


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RAO LAO Ablation of

Antegrade

SAVN

Ablation of

retrograde

intermediateAVN

C 2


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Case 2A 28 Y/O male fireman had recurrent attacks of tachycardia during exercise

RVOT-VT, PSVT with LBBB or Preexcited tachycardia?


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NSR (Intermittent Preexcitation)

AP location?


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RVS1S1 350 ms

350


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RVS1S1 340 ms

Sudden VA block

Favors AP

340


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RVS1S2 500/310 ms

F-S echo

RAS1S2 I d d T h di


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RAS1S2 Induced Tachycardia

Wide QRS complex tachycardia:VT?, or Preexcitated tachycardia? PSVT with LBBB

Wid QRS T h di


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Wide QRS Tachycardia

TCL= 256 ms


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Question?

Whats the mechanism of Wide QRS

complex tachycardia?VT? Preexcitated tachycardia? PSVT with

LBBB? Whats the next step to D.D?

PSVT with LBBB

VPC t i t t h di


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VPC terminate tachycardia

Can rule out AT

Without conduction to A

VPC


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VOP terminate tachycardia

Sudden VA block

AVNRT is not likely

No lower common pathway

The same A sequence


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Initiation of NQRS tachycardia

NQRS T h di


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NQRS Tachycardia

TCL= 244 ms shorter than SVT with LBBB (256 ms)

Favor left side AP?

VPC reset SVT


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VPC reset SVT

His refractory VPC

248 233

Abl ti it RPS


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Ablation site: RPS

S ithi 5 d


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Success within 5 seconds

VA block

RF on

I di i hi 5


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Immediate recurrence within 5

RF off


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Ablation site 1: RPS



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VA block

I di t ithi 3


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Immediate recurrence within 3


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Ablation site 2: RPS

Abl ti it LMS


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Ablation site: LMS



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VA block


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Ablation site 3: LMS

Transient CAVB


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Transient CAVB


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PS APs

(Chiang CE et al. Circulation 1996)


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MS APs

(Chang SL et al. JCE 2005)

TestSmall & narrow P waveRA & LA depolarization simultaneously

A P wave in the midpoint between the two QRS beats


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Test

Diagnosis: SF AVNRT with 2:1 AV block

A P wave in the midpoint between the two QRS beats

Test


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Test

AT with 2:1 AV block?

Whats the next step?

Test: VOP 2:1 to 1:1 conduction


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Test: VOP 2:1 to 1:1 conduction


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AVNRT VS AVRT

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