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