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Arrhythmia ECGTachycardia
林亮宇台大醫院內科部
Tachycardia
Surpa-ventricular tachycardia
Ventricular tachycardia
Ventricular fibrillation
Supra-ventricular tachycardia
From atria
-Atrial tahycardia: 100-250/min
-Atrial flutter: 250-350/min
-Atrial fibrillation > 350/min
From AV junction: Junctional tachycardia
Atrioventricular nodal reentrant tachycardia (AVNRT)
Atrioventricular reciprocating tachycardia (AVRT)
PSVT 之電生理分類：
1. 與 sinus node 有關者
sinus tachycardia
sinus node reentry tachycardia ( SAT )
2. 與 AV node 有關者 AV nodal reentry tachycardia ( AVNRT ) AV reentry tachycardia ( AVRT ) using accessory pathway
AVNRT: Slow-Fast (Common), Fast-Slow (Uncommon)
No “ P ” in Common Type, Clear “ P’ ” in Uncommon Type
AV NODAL EXTENSIONSAV NODAL EXTENSIONS
CS OS
Anterior extension Posterior
extension
Tricuspidhinge
Pre-excitationPre-excitation
Anatomical locations of Right vs. Left Accessory Pathways
Pre-excitationPre-excitation
Wide-Complex Tachycardia, r/o VT
Sinus Rhythm AVRT, Antidromic
Ebstein’s Anomaly, WPW Syndrome
Avoid CCB, BB, digoxin
PSVT 之電生理分類 ：
3. 與 atrial muscle 有關者
Atrial tachycardia
Atrial flutter
Atrial fibrillation
“AT” in A SSS Patient :Focal AT in RA
Atrial flutter
Typical Atrial Flutter: circuit & ablation
IVCO-TA isthmus
Focal to chaotic Atrial Fibrillation
Cont’d.
陣發 持續
Circumferential PV isolation by RFCA
Pappone C, Circulation 2000.
AVNRT, AVRT: carotid massage, adenosine, CCB, BB
AT, AF, Afib Rate control: CCB, BB, digoxin, amiodarone Rhythm control (within 48 hrs and for prophylatic): -Class IA: quinidine -Class IC: propafenone -Class III: amiodarone CardioversionLow perfusionAF, Afib within 48 hrs (TEE/anticoagulant)
Prevention of embolism AF, Afib RFCA for AVNRT, AVRT, AT, AF and Afib?
Management of SVT
Ventricular tachycardia
Idiopathic VT
-From RVOT
-From LV inferioapical septal region: ILVT
Organic VT
CAD
CHF
Cardiomyopathy: HCM, DCM,
VTVT
ECG of VT
Wide QRS complex (most VT)
Must be VT
VA block
Capture beat or fusion beat
Morphological criteria: favor VT
Precordial concordance
QRSd>140ms
VT: AV dissociationVT: AV dissociation
VT: VT: positive & positive & negative negative concordancconcordancee
Capture beatCapture beat
Idiopathic Ventricular TachycardiaIdiopathic Ventricular Tachycardia
DefinitionDefinition: ventricular arrhythmia that ori: ventricular arrhythmia that originate in hearts without structural diseaginate in hearts without structural diseasese
Right/ left ventricular outflow tract VT (ARight/ left ventricular outflow tract VT (Adenosine- sensitive VT)denosine- sensitive VT)
Left ventricular fascicular tachycardia (VLeft ventricular fascicular tachycardia (Verapamil- sensitive VT)erapamil- sensitive VT)
• Most Most common: common: RVOT, RVOT, LBBB and LBBB and inferior inferior axisaxis
• Less Less common: common: LVOT: LVOT: RBBB and RBBB and inferior inferior axisaxis
Idiopathic Left Ventricular Tachycardia
A-V Dissociation, RBBB and Superior Axis Favors VT,
Idiopathic Left Ventricular Tachycardia
A-V Dissociation, RBBB and Superior Axis Favors VT,
Management of VT
Idiopathic VT
-RVOT: adenosine or verapamil
-ILVT: verapamil
-Both amenable to RFCA
Organic VT
DC shock
Medication: Ib (lidocaine, mexitil), III (amiodarone, sotalol)
ICD, RFCA
Postulated Reentry Circuit in Post-Infarct VT (Stevenson WG, 1993)
Torsade de Pointes (TdP)
Long QT related
Early after depolarization (EAD)
R on T
Congenital or acquired (mostly drug)-
Female, 22 y/o
Torsade de PointesTorsade de Pointes
Management of TdP
Overdrive pacing
Isoproterenol
MgSO4
Beta-blockers
Remove offending agents
anti-histamine, antifungal, macrolide, AAD
With Structural heart disease
HCM, ARVD
Without structural heart disease
Long (short) QT syndrome: NA, K Channelopathy
Brugada syndrome: Na channel defect
Catecholaminergic polymoprhic VT: Ryanodine R defect
Hereditary SCD syndrome
Antzelevitch et al, JACC 2003; 41: 1665-71
Brugada Syndrome
Male, 32 y/o, Recurrent Seizures Brugada Syndrome : VF
V1
II
V5
aVF
V4
V6
CPVT Catecholaminergic Polymorphic Ventricular Tachycardia
Ryanodine receptor ( RyR2 ) mutation, rise of Ca i
Bi-directional VT: digoxin intoxication
Ventricular FibrillationVentricular Fibrillation
ICD indication for SCD prevention in:
Post-Infarction
Cardiomyopathy, ARVD
Heart failure
Brugada / LQTS/CPVT/SQTS
Idiopathic VF
Thank you for your attention
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