1. Complex SVT with differentiationAdvanced Cardiac
ArrhythmiaTraining Course( ) April 15, 2012
2. Supraventricular tachycardia (SVT) 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% 3. 12-lead ECG fordifferential
diagnosis of SVTs (important!) 4. Retrograde P wave in SVT (Tai CT
et al. JACC 1997) 5. Short RP SVT1. Slow-Fast AVNRT: No apparent
retrograde P wave: 50% Pseudo R in V1 or pseudo-S in inferior
leads: 50% (RP 50 ms Continuous curve AVNRT V induced SF AVNRT
AVNRT with retrograde eccentric activation Clinically documented,
non-inducible AVNRT(Lee SH, et al. AJC 1997) During 23+/-13 months
of follow-up, none of the16 patients with slow-pathway ablation
hadrecurrence of PSVT. However, 7 of the 11 patients without
ablationhad PSVT recurrence at 13+/-14 months offollow-up. (Lin JL
et al. JACC 1998) 17. Definitions Retrograde FAVN: short VA, HIS
earliest-Aand no decremental conduction. Retrograde SAVN: long VA,
CSO earliest-Aand decremental conduction. V pacing: long VA
interval with jump (>50 ms); Asequence changes from HIS to CSO
earliest2. SVT: AHHA) or F-I (AH70 ms)4. VA interval increases
>30 ms with functional BBB. 22. LT AP with LBBB (Josephson ME.
P237) 23. Single VPC reset SVT 24. His refractory VPC 35-55 ms
before the His deflection. Advance the following A: AVRT VPC
terminate the SVT withoutconducting to the atrium: rule out
AT,favors AVRT. VPC from the sites other than RVA:LV: for left side
APsRVOT: for septal APs 25. VPC reset SVT (FS AVNRT) No advance
AVA= 140 ms VA= 250 ms Lower common pathwaySame retrograde A
sequence 26. VPC reset SVT (AVRT) Advance A342 342 323378 His
refractory VPC 27. VPC terminates SVT (AVRT) Without conduction to
atrium, R/O ATHis refractory VPC, R/O AVNRT 28. Ventricular
Overdrive Pacing (VOP) (10-40 msshorter than tachycardia) during
SVT 29. VOP entrains the SVT VOP could not entrain SVT: AT The same
atrial activation sequence:AVNRT or AVRTThe 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: favorsAVNRT or AVRT. 30. VOP during SVT (FS
AVNRT)AV VV A V AV AV ASame retrograde A sequence Lower common
pathway 31. VOP during SVT (AT) A A V V1. The retrograde A sequence
is different during tachycardia and VOP 2. The presence of V-A-A-V
response during VOP (Veenhuyzen G. et al. PACE 2011) 32.
(Veenhuyzen G. et al. PACE 2011) 33. Ablation Strategy of AVNRT
Make a correct diagnosis!!! Ablation of antegrade or retrograde
slow AVN Anatomic approach: PMA Electrogram approach: A, V
(slowpotential) Junctional tachycardia during RF Mapping during V
pacing but ablation during SR(for retrograde SAVN only):
ABL-earliest A How to avoid AV block? Ablation during A pacing
Avoid ablation during SVT or V pacing. Quick hand! Quick leg! Quick
brain! (You have 34. Slow Potential 34 35. JT during ablation True
Junctional rhythm HHCS junctional rhythm35 36. Transient complete
AVBComplete AVB One second 36 37. Transient complete AVBComplete
AVB for more than 10 seconds37 38. SAVN Ablation SiteRAO 30 degree
LAO 60 degree38 39. Ablation site RAO 30 degree LAO 60
degreeRetrogradeSlow AVNAntegradeSlow AVN 40. Ablation Strategy of
AVRT Make a correct diagnosis!!!Localization of the APs: 12-lead
ECG algorithm and intracardiac recordings. A-V or V-A fusion or
earliest Antegrade approach: for RT AP Retrograde approach: for LT
AP6. V site (subvalvular): small A, large V, stable ablation
catheter7. A site (ante- or retro-grade): larger A, unstable
ablation catheter 41. Delta Wave in NSR(Chiang CE et al. AJC 1996)
42. Cases Discussion 43. Case 1: 12 lead ECG Long RP tachycardia
44. RAS1S2 induced PSVT A HA CSO-A earliestFS AVNRT? Orthodromic
AVRT? Or AT 45. VPC reset SVTNo advance the following AThe same
retrograde A sequence Increased the VA interval 46. VOP during
SVT:A AV V1. The same atrial activation sequence2. Progressive
prolongation of VA interval3. The presence of V-A-A-V response 47.
VOP changes SVT FS AVNRTSF AVNRT 48. Another SVT SF AVNRT 49.
Successful ablation site 50. JT during RF 51. PR prolongation
during RF 52. VA dissociation after Ablation 53. Successful
ablation site 54. Case 2: 12 lead ECGRP>70 ms 55. RVS1S1 350 ms
His-A earliest CS ostium at 5,6? 56. RAS1S1 550 ms 57.
RAS1S1+isuprel induced PSVT AH ACS9,10-A earliest AH~=HA 58. PSVT
59. VPC terminates SVT AT is not likely 60. RVS1S1 350 ms+
isuprelIncreased VA interval Fusion FAVN 61. VPC Reset SVT No
advance A 62. VOP during SVT No decremental conduction 63. VPC
reset SVT VPC advance A 64. Successful ablation site 65. Successful
ablation 66. Successful ablation siteRAO LAO 67. Unknown Tracings
68. Small & narrow P waveRA & LA depolarization
simultaneouslyTest 1 A P wave in the midpoint between the two QRS
beatsDiagnosis: SF AVNRT with 2:1 AV block 69. Test 1AT with 2:1 AV
block?Whats the next step? 70. Test 1: VOP 2:1 to 1:1 conduction
71. Test 2A 57 Y/O male patient had an arrhythmic attack during
hospitalization.PSVT with (RBBB) cycle length alternans and a fixed
short RP intervalCycle length alternans due to one longer and
another shorter PR intervalDiagnosis: Orthodromic AVRT with dual
AVN physiologyInitiation? 72. Test 2:RAS1S2 500/380 ms One P with
three Q1. FAVN2. SAVN3. AVRT echo 73. Test 2: Spontaneous
Initiation of SVTOne P with Two QOrthodromic AVRT with antegrade
FAVN and retrograde LL AP 74.
