A Technique for the Rapid Diagnosis of Wide Complex Tachycardia with 1:1 AV Relationship in the Electrophysiology Laboratory (original) (raw)

A novel pacing manoeuvre to diagnose atrial tachycardia

Europace, 2008

Aims Currently used diagnostic manoeuvres at the electrophysiology study do not always allow for consistent identification of atrial tachycardia (AT), either because of inapplicability of the technique or because of low predictive value and specificity. The aim of this study was to determine whether overdrive atrial pacing during paroxysmal supraventricular tachycardia (SVT) with the same cycle length from both the high right atrium and the coronary sinus can accurately identify or exclude AT by examining the difference between the V-A intervals of the first returning beat of tachycardia between the two pacing sites. Methods and results Fifty-two patients were included; 24 patients with atrioventricular nodal re-entry tachycardia (AVNRT), 13 patients with atrioventricular re-entry tachycardia (AVRT), and 15 patients with AT. Comparing the 37 non-AT patients with the 15 AT patients, there was a highly significant difference between the mean V-A interval difference, (delta V-A) 2.1 + 1.8 ms (range 0-9 ms) vs. 79.1 + 42 (range 22-267 ms) (P , 0.001), respectively. None of the patients in the non-AT group had a delta V-A . 10 ms. In contrast, all 15 patients with AT had a delta V-A interval .10 ms. Thus, the diagnostic accuracy of the delta V-A interval cut-off of .10 ms was 100%, with a 95% confidence interval of 93.1-100% for AT. In 11 (73%) of the 15 AT patients, the standard ventricular overdrive pacing manoeuvre was not possible. In 14 of the 15 patients (93%) in the AT group, standard atrial overdrive pacing showed variable V-A intervals, correctly diagnosing AT. In all 52 patients, this measurement was repeated during pacing from the other location. In five patients from the AT group, the result of the second attempt was different from the result of the first attempt. Conclusion We found that atrial differential pacing during paroxysmal SVT without termination of tachycardia and the finding of variable returning V-A interval was highly sensitive and specific for the diagnosis of AT. The manoeuvre can be easily performed in all patients with SVT and is highly reproducible. It is a useful adjunct to the currently available ventricular and atrial pacing manoeuvres.

Wide complex tachycardia in a patient with paroxysmal atrial fibrillation

Heart Rhythm, 2008

A 63-year old man was admitted to the hospital for catheter ablation of paroxysmal atrial fibrillation. He first experienced recurrent episodes of palpitations and weakness related to atrial fibrillation in 2001. Treatment with oral amiodarone was discontinued a few months later because of development of thyroiditis. A Medtronic AT500 dual-chamber pacemaker was implanted in 2005. Symptoms of palpitations increased in frequency and became daily, requiring repeated hospitalizations. On the day before the ablation procedure, a wide complex tachycardia was recorded on the telemetry monitor. Onset and 12-lead ECG of the tachycardia are shown in . The patient remained in this tachycardia for 2 hours until pacemaker interrogation was performed ( ).The tachycardia terminated as soon as the pacemaker wand was applied. What is the mechanism of this tachycardia?

Successful Ablation of a Wide Complex Tachycardia with Distinct Intra-Cardiac Electrograms

A 13-year-old boy was hospitalized after a syncopal episode that occurred during exercise. He suddenly felt chest tightness, sweating and palpitations, followed by a transient loss of conciseness. Upon emergency medical team arrival, he was awake and oriented. Baseline ECG showed sinus rhythm at a rate of 98 bpm, with narrow QRS, and no signs of long QT, Brugada, or pre-excitation. Physical examination, blood tests, 24 hours Holter monitoring, transthoracic echocardiography and stress test were all within normal limits. Eight days later he experienced a second episode of palpitations while walking to school. ECG revealed regular wide complex tachycardia (WCT) at a rate of 200 bpm, with LBBB morphology that terminated with Adenosine (Figure 1). The clinical tachycardia was easily induced by programmed electrical stimulation (Figure 2A). Diagnostic electrophysiological maneuver (Figure 2B) was followed by successful ablation, during which a unique phenomenon was noted (Figure 3). What...

Wide complex tachycardia in a patient with a dual chamber pacemaker

Europace, 2008

An 81-year-old patient was admitted to the coronary care unit due to unstable angina and respiratory distress after urgent eye surgery for retinal detachment. He had a medical history of hypertension, diabetes mellitus, coronary artery disease, and valvular heart disease. He underwent coronary artery bypass grafting and aortic valve replacement in 1998 and received a dual chamber pacemaker (Pulsar Max DR Guidant/Boston Scientific Natick, MA, USA) for third-degree heart block in 1999. The diagnosis of myocardial infarction complicated by acute pulmonary oedema was withheld, in view of a rise in troponin I level to a maximum of 14.66 mg/L (normal value ,0.14 mg/L). ST-segment elevation could not be assessed because of ventricular pacing ( . He developed respiratory failure for which mechanical ventilation was initiated. His echocardiography showed a depressed left ventricular function with an ejection fraction of 30% due to a large antero-lateral myocardial infarction. An urgent coronary angiography showed a critical stenosis of the left coronary artery, and a percutaneous coronary intervention of the native left anterior descending and circumflex artery was performed.

Atypical Response to Diagnostic Maneuvers in a Narrow QRS Tachycardia: What is the Mechanism?

Pacing and Clinical Electrophysiology, 2015

Case Presentation A 69-year-old woman without known cardiopathy was referred to our unit for an electrophysiological (EP) study, due to a history of paroxysmal episodes of palpitations with sudden onset and termination. She was being treated with verapamil and flecainide, with mild clinical improvement. For the EP study, a decapolar catheter was placed in the coronary sinus (CS), a tetrapolar catheter at the right ventricular apex (RVA), and a 4-mm-tip ablation catheter at the bundle of His. Baseline electrocardiogram showed sinus rhythm, but programmed ventricular stimulation with extrastimuli performed to study retrograde conduction, triggered a narrow QRS tachycardia (Fig. 1A). This tachycardia was also easily triggered with overdrive atrial pacing using different S1-S1 intervals (Fig. 1B). Response of the tachycardia to single atrial extrastimuli with different coupling intervals is shown in Figure 2. To perform these maneuvers, the RVA tetrapolar catheter was placed in the His bundle region, in order to improve His signal visualization. No isoproterenol infusion was used during the procedure. What is the mechanism of the tachycardia? Commentary Ventricular programmed stimulation showed concentric and decremental V-A conduction (Fig. 1A), indicating V-A conduction used the Funding sources: None.

Introduction to Supraventricular Tachycardia

Cardiac Electrophysiology Clinics, 2010

Paroxysmal supraventricular tachycardia (PSVT) is a clinical syndrome characterized by a rapid tachycardia with an abrupt onset and termination. These arrhythmias are frequently encountered in otherwise healthy patients without structural heart disease. Symptoms vary from palpitations and dyspnea to tachycardia-induced cardiomyopathy. The three most common causes of PSVT are atrioventricular nodal reentrant tachycardia (AVNRT) (50%-60%), atrioventricular reentrant tachycardia (AVRT) in patients with Wolff-Parkinson-White syndrome (25%-30%), and atrial tachycardia (10%). Rare causes of PSVT include focal junctional tachycardia, atriofascicular tachycardia, permanent reciprocating junctional tachycardia, and nodoventricular/nodofascicular tachycardia. This section, based on challenging PSVT cases, is a guide for clinicians dealing with diagnostic or therapeutic dilemmas in the electrophysiology laboratory.

Catheter Ablation of Accessory Pathway in the Treatment of Pacemaker-Mediated Tachycardia

Pacing and Clinical Electrophysiology, 2012

Pacemaker-mediated tachycardia (PMT) remains a clinical problem in patients with dual-chamber pacemaker despite technological advances. The onset mechanism of this tachycardia is sensing of retrograde atrial activation after ventricular stimulation. Repeated retrograde conduction perpetuates tachycardia. Postventricular atrial refractory period prolongation has been used for prevention of PMT, but this is not the solution in all cases. We present a case with PMT where the retrograde limb is a left accessory pathway, which is treated with radiofrequency ablation successfully. (PACE 2012; 35:e74-e76)