clinical practice Supraventricular Tachycardia (original) (raw)
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American Heart Journal, 1984
Programmed electrical stimulation of the heart has improved our knowledge of the site of origin, mechanisms, and pathways of supraventricular tachycardia (SVT) in humans. l-2 This has resulted in a more rational therapeutic approach to the different types of SVT and the development of refined surgical techniques for some of them.3-4 It has also increased our ability to make the correct diagnosis on the 12-lead ECG in patients with SVT.5 We have recently reported on patients with sustained atrioventricular (AV) junctional tachycardia showing a P-R interval shorter than the R-P interval6 It was demonstrated that an intranodal location of the reentry circuit (the so-called "uncommon type" of AV nodal tachycardia) during this arrhythmia is unlikely. These patients have a circus movement tachycardia using in the AV direction the normal AV nodal His-Purkinje pathway and in the ventriculoatrial (VA) direction an accessory pathway with long conduction times and AV nodal-like properties. Usually these patients present clinically with a tachycardia having an almost incessant or "permanent" character.7 Atria1 tachycardia can present with a similar ECG and clinical picture. Also, in view of the therapeutic implications, we would like to discuss how to differentiate between both types of SVT. Special empha-From the
Circulation, 2015
A trioventricular nodal reentrant tachycardia (AVNRT), which uses pathways within the atrioventricular node as critical limbs of reentrant circuits, has been divided among slow-fast, fast-slow (F/S), and slow-slow forms on the basis of the relative duration of atrio-His (AH) versus His-atrial (HA) conduction and the site of earliest atrial activation during the tachycardia. 1 F/S-AVNRT, characterized by a longer HA than AH interval and an earliest site of atrial activation in the posteroseptal region, incorporates a fast pathway (FP) as the anterograde limb and a typical slow pathway (SP) oriented inferiorly as the retrograde limb. 1 Several investigators, however, have described a rare subtype of F/S-AVNRT, with a site of earliest activation located in the superior aspect of the Koch triangle near the His bundle (HB), referred to here as sup-F/S-AVNRT, 2,3 which has not been widely accepted as a distinct supraventricular tachyarrhythmia. Furthermore, an atypical and distinct arrhythmogenic atrioventricular nodal substrate responsible for sup-F/S-AVNRT has not been confirmed electrophysiologically, although an atypical SP anterior to the FP has been suspected in rare cases of AVNRT. 4,5 This retrospective, multicenter study was designed to confirm the existence of a sup-F/S-AVNRT, with a focus on the presence and characteristics of a "superior" SP located in the HB region and used as the retrograde limb of the reentrant circuit. Clinical Perspective on p 123 Methods We retrospectively identified 6 women and 2 men 74±7 years of age (range, 59-82 years) who underwent successful ablation of a Background-The existence of an atypical fast-slow (F/S) atrioventricular nodal reentrant tachycardia (AVNRT) including a superior (sup) pathway with slow conductive properties and an atrial exit near the His bundle has not been confirmed. Methods and Results-We studied 6 women and 2 men (age, 74±7 years) with sup-F/S-AVNRT who underwent successful radiofrequency ablation near the His bundle. Programmed ventricular stimulation induced retrograde conduction over a superior SP with an earliest atrial activation near the His bundle, a mean shortest spike-atrial interval of 378±119 milliseconds, and decremental properties in all patients. sup-F/S-AVNRT was characterized by a long-RP interval; a retrograde atrial activation sequence during tachycardia identical to that over a sup-SP during ventricular pacing; ventriculoatrial dissociation during ventricular overdrive pacing of the tachycardia in 5 patients or atrioventricular block occurring during tachycardia in 3 patients, excluding atrioventricular reentrant tachycardia; termination of the tachycardia by ATP; and a V-A-V activation sequence immediately after ventricular induction or entrainment of the tachycardia, including dual atrial responses in 2 patients. Elimination or modification of retrograde conduction over the sup-SP by ablation near the right perinodal region or from the noncoronary cusp of Valsalva eliminated and confirmed the diagnosis of AVNRT in 4 patients each. Conclusions-sup-F/S-AVNRT is a distinct supraventricular tachycardia, incorporating an SP located above the Koch triangle as the retrograde limb, that can be eliminated by radiofrequency ablation.
The American Journal of Cardiology, 1989
His bundle electrogram; this was the same activation sequence as during the basic drive ( . A ven-Naoto Yamamoto, MD, Ken-ichiro Ohtomo, MD, Kenzo Hirao, MD, tricular extrastimulus at a coupling and Kazumasa Hiejima, MD I t has been assumed that the reentry circuit in so-called atrioventricular (AV) nodal reentrant tachycardia with both slow-fast (or common) and fast-slow (or uncommon) forms is entirely intranodal.1,2 Such an assumption is, however, based not on the direct electrophysiologic evidence but indirectly on the exclusion of atria1 and ventricular myocardium as essential parts of the reentry circuit. In addition, it has recently been proposed that extranodal atria1 fibers may form part of the reentrant circuit and that surgical division of these fibers will abolish AV nodal reentrant tachycardia while preserving AV conduction.3,4 We report on a patient with AV nodal reentrant tachycardia of fast-slow form in which some electrophysiologic evidence of probable atria1 participation in the reentrant circuit was elucidated.
Atrioventricular nodal reentrant tachycardia: studies on upper and lower 'common pathways
Circulation, 1987
Electrophysiologic studies were performed in 28 patients with documented atrioventricular (AV) nodal reentrant supraventricular tachycardia (SVT) to investigate the presence of AV nodal tissue situated between the tachycardia circuit and both the atrium (upper common pathway, UCP) and the His bundle (lower common pathway, LCP). All patients demonstrated a 1:1 AV relationship during SVT. The study protocol consisted of atrial then ventricular pacing at the SVT cycle length. UCPs were manifested in eight of 28 (29%) patients by either antegrade AV Wenckebach (six patients) or a paced atrium-His (AH) interval exceeding the AH in SVT (two patients, differences 5 and 9 msec). LCPs were manifested in 21 of 28 (75%) patients by either retrograde Wenckebach periodicity (two patients) or a paced HA interval exceeding the HA in SVT (19 patients, mean difference 25 +/- 20 msec). By these criteria, eight patients (29%) had evidence for both UCPs and LCPs. UCPs were more likely than LCPs to be m...
The American Journal of Cardiology, 2000
This study assessed antidromic reciprocating tachycardia (ART) in patients with paraseptal accessory pathways (APs). Previous clinical experience suggests that paraseptal APs are unable to serve as the anterograde limb during ART. Based on the reentry wavelength concept, we hypothesized that anatomic location of a paraseptal AP may not preclude occurrence of ART. If wavelength criteria were met due to prolonged conduction time retrogradely in the atrioventricular node or anterogradely in the AP, ART may be sustained. All patients who had ART in the electrophysiologic laboratory at our institution (1991 to 1998) were studied. Based on fluoroscopically guided electrophysiologic mapping and radiofrequency ablation, AP location was classified as paraseptal, posterior, or lateral. Conduction time and refractoriness measurements were made for all components of the ART circuit. Of 24 patients with ART, 5 (21%) had ART utilizing a paraseptal AP. Anterograde conduction time through the AP and retrograde atrioventricular nodal conduction time were significantly longer in patients with paraseptal versus lateral pathways. Isoproterenol was required for ART induction in 38% of patients with a posterior AP, 36% with lateral AP location, but not in patients with a paraseptal AP. There were no significant differences in tachycardia cycle length or refractoriness of anterograde and/or retrograde components of the macroreentry circuit between the 3 pathway locations. Thus, ART can occur in patients with a paraseptal AP. Slower anterograde pathway conduction, or retrograde atrioventricular nodal conduction renders the wavelength critical for completion of the antidromic reentrant circuit.
Heart Rhythm, 2007
BACKGROUND The retrograde fast pathway in typical atrioventricular nodal reentrant tachycardia (AVNRT) exhibits marked variation in its electrophysiologic properties. OBJECTIVE The purpose of this study was to characterize the retrograde fast pathway and localize the lower turnaround site of the reentrant circuit in typical AVNRT. METHODS Seventy-four patients with typical AVNRT were divided into two groups according to the response of the retrograde fast pathway to intravenous administration of adenosine triphosphate (ATP) during ventricular pacing: ATP-S [n ϭ 47 (63.5%)] with and ATP-R without [n ϭ 27 (36.5%)] His-atrial (H-A) block. H-A intervals were measured from the most proximal His-bundle electrogram to the earliest atrial activation during the tachycardia (HAt) and entrainment pacing from the parahisian right ventricular region (HAe). It was postulated that the HAt was the difference in conduction time between the lower common pathway (x) and retrograde fast pathway (y) (HAt ϭ y Ϫ x), whereas HAe was the sum of the two (HAe ϭ y ϩ x). Hence, x ϭ (HAeϪHAt)/2. x Ͼ0 suggested the presence of a lower common pathway, whereas x Ͻ0 suggested the absence of a lower common pathway and lower turnaround site within the His bundle. RESULTS x was significantly smaller in ATP-R than ATP-S (Ϫ6 Ϯ 5 vs 4 Ϯ 4 ms, P Ͻ.05) and was Ͻ0 in 23 (85%) of 27 ATP-R patients. The maximal increment in H-A interval during ventricular pacing was significantly longer in ATP-S than ATP-R (35 Ϯ 33 vs 2 Ϯ 2 ms, P Ͻ.05). CONCLUSION A concealed atriohisian tract totally bypassing the atrioventricular node constituted the retrograde fast pathway in one third of all typical AVNRT cases.
Pacing and Clinical Electrophysiology, 2010
Entrainment from the right ventricular (RV) apex and the base has been used to distinguish atrioventricular reentrant tachycardia (AVRT) from atrioventricular nodal reentry tachycardia (AVNRT). The difference in the entrainment response from the RV apex in comparison with the RV base has not been tested. Fifty-nine consecutive patients referred for ablation of supraventricular tachycardia (SVT) were included. Entrainment of SVT was performed from the RV apex and base, pacing at 10-40-ms faster than the tachycardia cycle length. SA interval was calculated from stimulus to earliest atrial electrogram. Ventricle to atrium (VA) interval was measured from the RV electrogram (apex and base) to the earliest atrial electrogram during tachycardia. The SA-VA interval from apex and base was measured and the difference between them was calculated. Thirty-six AVNRT and 23 AVRT patients were enrolled. Mean age was 44 ± 12 years; 52% were male. The [SA-VA]apex-[SA-VA]base was demonstrable in 84.7% of patients and measured -9.4 ± 6.6 in AVNRT and 10 ± 11.3 in AVRT, P < 0.001. The difference was negative for all AVNRT cases and positive for all septal accessory pathways (APs). The difference between entrainment from the apex and base is readily performed and is diagnostic for all AVNRTs and septal APs.