Resetting criteria during ventricular overdrive pacing successfully differentiate orthodromic reentrant tachycardia from atrioventricular nodal reentrant tachycardia despite interobserver disagreement concerning QRS fusion (original) (raw)

Abstract

BACKGROUND The beginning of ventricular overdrive pacing (VOP) during supraventricular tachycardia (SVT) accurately distinguishes orthodromic reentrant tachycardia (ORT) from atrioventricular nodal reentrant tachycardia (AVNRT) even when pacing terminates tachycardia. Tachycardia resetting most often occurs during this transition zone (TZ) of QRS fusion in ORT and after this TZ in AVNRT. The end of the TZ is marked by the first beat with a stable QRS morphology but is a subjective assessment. Disagreement concerning this beat may change tachycardia diagnosis.

Figures (7)

Figure 1 —‘ Transition zone (TZ) identified on 12-lead ECG. SM1 indicates first beat of stable morphology i.e. last beat of TZ. Careful inspection of all 12 leads shows subtle differences in QRS morphology between the last fused beat and SM1. F = fusion between pacing wavefront and tachycardia circuit; SM = beat of stable morphology.

Figure 1 —‘ Transition zone (TZ) identified on 12-lead ECG. SM1 indicates first beat of stable morphology i.e. last beat of TZ. Careful inspection of all 12 leads shows subtle differences in QRS morphology between the last fused beat and SM1. F = fusion between pacing wavefront and tachycardia circuit; SM = beat of stable morphology.

Two criteria were used to evaluate resetting of the tachycardia: (1) atrial timing perturbation, defined as 210 ms change in

Two criteria were used to evaluate resetting of the tachycardia: (1) atrial timing perturbation, defined as 210 ms change in

atrial—atrial timing (advance or delay) at the site of earliest atrial activation or abrupt VA block, and (2) fixed stimulation- to-atrial (SA) interval, measured between ventricular pacing stimulus to earliest atrial activation and considered fixed when the SA varied by =10 ms. Interobserver variability for iden- tifying atrial timing perturbation and fixed SA was evaluated.

atrial—atrial timing (advance or delay) at the site of earliest atrial activation or abrupt VA block, and (2) fixed stimulation- to-atrial (SA) interval, measured between ventricular pacing stimulus to earliest atrial activation and considered fixed when the SA varied by =10 ms. Interobserver variability for iden- tifying atrial timing perturbation and fixed SA was evaluated.

Figure 4 A: Orthodromic reentrant tachycardia in a patient with a decrementally conducting septal accessory pathway. Atrial timing is de- layed with the first beat of right ventricular pacing diagnostic of ortho- dromic reentrant tachycardia. The stimulation-to-atrial interval (SA) be- comes fixed during the transition zone (TZ), two beats before SM1. B: Atypical atrioventricular nodal reentrant tachycardia. Atrial timing is not altered, and the SA does not become fixed until SM3 and SM4, respec- tively, well after the end of the TZ. F = fusion between pacing wavefront and tachycardia circuit; SM = beat of stable morphology. ular extrastimulus that occurred when the His bundle was refractory!°-!*; (2) VA interval during tachycardia increased by =20 ms with the development of ipsilateral bundle

Figure 4 A: Orthodromic reentrant tachycardia in a patient with a decrementally conducting septal accessory pathway. Atrial timing is de- layed with the first beat of right ventricular pacing diagnostic of ortho- dromic reentrant tachycardia. The stimulation-to-atrial interval (SA) be- comes fixed during the transition zone (TZ), two beats before SM1. B: Atypical atrioventricular nodal reentrant tachycardia. Atrial timing is not altered, and the SA does not become fixed until SM3 and SM4, respec- tively, well after the end of the TZ. F = fusion between pacing wavefront and tachycardia circuit; SM = beat of stable morphology. ular extrastimulus that occurred when the His bundle was refractory!°-!*; (2) VA interval during tachycardia increased by =20 ms with the development of ipsilateral bundle

Table 1 Baseline characteristics of the study patients

Table 1 Baseline characteristics of the study patients

Figure 5 —‘ Transition zone (TZ) of a patient with typical atrioventricular nodal reentrant tachycardia (AVNRT). If the beat in question (?) is considered the first beat of stable morphology, the tachycardia circuit is reset after the TZ, correctly diagnosing AVNRT. However, if the beat in question is fused, the tachycardia circuit is reset during the TZ. This would incorrectly diagnose orthodromic reentrant tachycardia in this patient. F = fusion between pacing wavefront and tachycardia circuit, SM = beat of stable morphology.

Figure 5 —‘ Transition zone (TZ) of a patient with typical atrioventricular nodal reentrant tachycardia (AVNRT). If the beat in question (?) is considered the first beat of stable morphology, the tachycardia circuit is reset after the TZ, correctly diagnosing AVNRT. However, if the beat in question is fused, the tachycardia circuit is reset during the TZ. This would incorrectly diagnose orthodromic reentrant tachycardia in this patient. F = fusion between pacing wavefront and tachycardia circuit, SM = beat of stable morphology.

AVNRT = atrioventricular nodal reentrant tachycardia; CI = confidence interval; ORT = orthodromic reentrant tachycardia; PPV = positive predictive value; SA = stimulation-atrial time interval; TZ = transition zone. Table 2. Sensitivity, specificity, and positive predictive value for TZ resetting criteria

AVNRT = atrioventricular nodal reentrant tachycardia; CI = confidence interval; ORT = orthodromic reentrant tachycardia; PPV = positive predictive value; SA = stimulation-atrial time interval; TZ = transition zone. Table 2. Sensitivity, specificity, and positive predictive value for TZ resetting criteria

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