Scribd Logo
Upload

Welcome to Scribd!

  • 415 views

    Avnrt VS Avrt

    Uploaded by

    Dwi Nugroho Prastowo
    1. The document discusses the differential diagnosis and treatment of various supraventricular tachycardias including AV nodal reentrant tachycardia (AVNRT), atrioventricular reentrant tachycardia (AVRT), and atrial tachycardia (AT). 2. Electrophysiology study findings that help differentiate the arrhythmias are discussed, such as dual AV nodal physiology favoring AVNRT or eccentric atrial activation with short VA interval favoring AVRT. 3. Ablation techniques for each arrhythmia include targeting the slow or intermediate AV node for AVNRT or locating the accessory pathway and ablating the antegrade or retrograde limb for

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Avnrt VS Avrt

    Uploaded by

    Dwi Nugroho Prastowo
    415 views79 pages
    1. The document discusses the differential diagnosis and treatment of various supraventricular tachycardias including AV nodal reentrant tachycardia (AVNRT), atrioventricular reentrant tachycardia (AVRT), and atrial tachycardia (AT). 2. Electrophysiology study findings that help differentiate the arrhythmias are discussed, such as dual AV nodal physiology favoring AVNRT or eccentric atrial activation with short VA interval favoring AVRT. 3. Ablation techniques for each arrhythmia include targeting the slow or intermediate AV node for AVNRT or locating the accessory pathway and ablating the antegrade or retrograde limb for

    Original Description:

    different between supraventricular tachyarithmia

    Original Title

    AVNRT VS AVRT

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    1. The document discusses the differential diagnosis and treatment of various supraventricular tachycardias including AV nodal reentrant tachycardia (AVNRT), atrioventricular reentrant tachycardia (AVRT), and atrial tachycardia (AT). 2. Electrophysiology study findings that help differentiate the arrhythmias are discussed, such as dual AV nodal physiology favoring AVNRT or eccentric atrial activation with short VA interval favoring AVRT. 3. Ablation techniques for each arrhythmia include targeting the slow or intermediate AV node for AVNRT or locating the accessory pathway and ablating the antegrade or retrograde limb for

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    415 views79 pages

    Avnrt VS Avrt

    Uploaded by

    Dwi Nugroho Prastowo
    1. The document discusses the differential diagnosis and treatment of various supraventricular tachycardias including AV nodal reentrant tachycardia (AVNRT), atrioventricular reentrant tachycardia (AVRT), and atrial tachycardia (AT). 2. Electrophysiology study findings that help differentiate the arrhythmias are discussed, such as dual AV nodal physiology favoring AVNRT or eccentric atrial activation with short VA interval favoring AVRT. 3. Ablation techniques for each arrhythmia include targeting the slow or intermediate AV node for AVNRT or locating the accessory pathway and ablating the antegrade or retrograde limb for

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 79

    Advanced AVNRT and AVRT

    With differentiation
    Advanced EP Training
    ()

    April 24, 2011


    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% or
    slow AP 10%)
    3. AT (n=245): 8%
    Supraventricular tachycardia (SVT)
    12-lead ECG for
    differential diagnosis
    of SVTs (important!)
    Retrograde P wave in SVT
    (Tai CT et al. JACC 1997)
    Short RP SVT
    1. Slow-Fast AVNRT:
    No apparent retrograde P wave: 50%
    Pseudo R in V1 or pseudo-S in inferior
    leads: 50%
    2. Orthodromic AVRT: 70 ms<RP<PR
    The presence of delta wave in NSR.
    3. AT with PR prolongation: the presence of
    AV block favors AT.
    S-F AVNRT
    Pseudo-R
    Pseudo-S
    NSR after IV adenosine
    No pseudo-R and pseudo-S
    S-F AVNRT
    No apparent P wave
    S-F AVNRT
    P wave masked by QRS
    S-F AVNRT
    Pseudo-R and pseudo-S
    S-F AVNRT
    Pseudo-R and pseudo-S
    Orthodromic AVRT
    RP>70 ms, favor LL AP
    MWPW (LL or LAL AP)
    Long RP SVT
    1. Fast-Slow AVNRT:
    Positive p wave in V1 and negative p
    wave in inferior leads.
    2. Orthodromic AVRT using decremental
    (slow) APs.
    3. AT with normal PR interval.
    EP study for
    differential diagnosis
    of SVTs
    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-V
    or A before V (SF AVNRT)
    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 interval
    2.His-A and CSO-A both earlier
    AVNRT with retrograde eccentric
    activation
    Continuous curve AVNRT
    (Tai CT et al. Circulation 1997)
    Initiation of S-F AVNRT
    Progressive AH prolongation with jump
    Lower common pathway
    V
    V V V
    A A
    A
    A
    Progressive prolongation of VA interval
    AVNRT with eccentric A activation
    (Ong M. et al. IJ C 2007)
    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.
    LT AP with LBBB
    (Josephson ME. P237)
    Single VPC reset SVT
    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 APs
    RVOT: for septal APs
    Ventricular Overdrive
    Pacing (VOP) (10-40 ms
    shorter than tachycardia)
    during SVT
    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.
    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
    Hirao, K. et al. Circulation 1996;94:1027-1035
    Para-Hisian pacing
    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. J T during RF
    How to avoid AV block?
    1. ablation during A pacing
    2. avoid ablation during SVT or V pacing.
    3. You have only one second to stop RF!!!
    JT under during RF
    Transient second degree AVB
    Flat and horizontal Kochs Triangle
    (Lee PC et al. Curr Opin Cardiol. 2009)
    RAO LAO
    Ablation Strategy of AVRT
    Make a correct diagnosis!!!
    Localization of the APs: 12-lead ECG
    algorithm and intracardiac recordings.
    Antegrade approach: for RT AP
    Retrograde approach: for LT AP
    1. V site (subvalvular): small A, large V, stable
    ablation catheter
    2. A site (ante- or retro-grade): larger A, unstable
    ablation catheter
    Delta Wave in NSR
    (Chiang CE et al. AJC 1996)
    Whats on the other side

    Cases Discussion
    Case 1
    VT, PSVT with RBBB or preexcitated tachycardia?
    RA burst + Isuprel induce SVT
    AVNRT with Wenkebach AV block then 1:1 conduction
    Whats the mechanism of SVT?
    S-F AVNRT
    PSVT with LBBB
    RVS1S2 induced PSVT
    500 270
    Retrograde-intermediate AVN or AP?
    AH=188 ms HA=158 ms
    VPC terminate SVT: AVN or AP?
    347 ms 347 ms
    293 ms
    V pacing during SVT: AVN or AP?
    350 ms
    372 ms
    Lower common pathway
    Mapping retrograde pathway and terminate
    SVT (after ablation of antegrade SAVN)
    RAO LAO
    Ablation of
    Antegrade
    SAVN
    Ablation of
    retrograde
    intermediate
    AVN
    Case 2
    A 28 Y/O male fireman had recurrent attacks of tachycardia during exercise
    RVOT-VT, PSVT with LBBB or Preexcited tachycardia?
    NSR
    (Intermittent Preexcitation)
    AP location?
    RVS1S1 350 ms
    350
    RVS1S1 340 ms
    Sudden VA block
    Favors AP
    340
    RVS1S2 500/310 ms
    F-S echo
    RAS1S2 Induced Tachycardia
    Wide QRS complex tachycardia:
    VT?, or Preexcitated tachycardia? PSVT with LBBB
    Wide QRS Tachycardia
    TCL= 256 ms
    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 terminate tachycardia
    Can rule out AT
    Without conduction to A
    VPC
    VOP terminate tachycardia
    Sudden VA block
    AVNRT is not likely
    No lower common pathway
    The same A sequence
    Initiation of NQRS tachycardia
    NQRS Tachycardia
    TCL= 244 ms shorter than SVT with LBBB (256 ms)
    Favor left side AP?
    VPC reset SVT
    His refractory VPC
    248 233
    Ablation site: RPS
    Success within 5 seconds
    VA block
    RF on
    Immediate recurrence within 5
    RF off
    Ablation site 1: RPS
    Success within 3 seconds
    VA block
    Immediate recurrence within 3
    Ablation site 2: RPS
    Ablation site: LMS
    Success within 5 seconds
    VA block
    Ablation site 3: LMS
    Transient CAVB
    PS APs
    (Chiang CE et al. Circulation 1996)
    MS APs
    (Chang SL et al. JCE 2005)
    Test
    Small & narrow P waveRA & LA depolarization simultaneously
    Diagnosis: SF AVNRT with 2:1 AV block
    A P wave in the midpoint between the two QRS beats
    Test
    AT with 2:1 AV block?
    Whats the next step?
    Test: VOP 2:1 to 1:1 conduction

    You might also like