1. Advanced AVNRT and AVRT With differentiation Advanced EP
Training() April 24, 2011
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%2. Orthodromic AVRT: 70 ms70 ms, favor LL AP 13. MWPW (LL
or LAL AP) 14. Long RP SVT1. Fast-Slow AVNRT: Positive p wave in V1
and negative p wave in inferior leads.2. Orthodromic AVRT using
decremental (slow) APs.3. AT with normal PR interval. 15. EP study
fordifferential diagnosisof SVTs 16. Favors AVNRT1. The presence of
dual AVN physiology: upper or lower common pathway.2. The critical
prolongation (jump) of AH interval during the initiation of SVT.3.
The concentric atrial activation: especially a straight line from
ECG-A-V or A before V (SF AVNRT) 17. AVNRT Antegrade SAVN: AH jump
> 50 ms Continuous curve AVNRT Retrograde SAVN:1.Long VA
interval2.CSO-A earliest. Retrograde intermediate
AVN:1.Intermediate VA interval2.His-A and CSO-A both earlier AVNRT
with retrograde eccentricactivation 18. Continuous curve AVNRT(Tai
CT et al. Circulation 1997) 19. Initiation of S-F AVNRT Progressive
AH prolongation with jump 20. Lower common of VA
intervalProgressive prolongation pathway V A V AV AV A 21. AVNRT
with eccentric A activation(Ong M. et al. IJC 2007) 22. Favors
AVRT1. No decremental conduction during pacing (except slow AP).2.
The eccentric atrial activation with short VA interval (>70
ms)3. VA interval increases >30 ms with functional BBB. 23. LT
AP with LBBB (Josephson ME. P237) 24. Single VPC reset SVT 25. His
refractory VPC 35-55 ms before the His deflection. Advance the
following A: AVRT VPC without conducting to atrium butterminate the
SVT: rule out AT. VPC from the sites other than RVA:LV: for left
side APsRVOT: for septal APs 26. Ventricular Overdrive Pacing (VOP)
(10-40 msshorter than tachycardia) during SVT 27. 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. 28. VOP during SVT A A V VAT1. The retrograde
A sequence is different during tachycardia and VOP2. The presence
of V-A-A-V response during VOP (Veenhuyzen G. et al. PACE 2011) 29.
Para-Hisian pacingHirao, K. et al. Circulation 1996;94:1027-1035
30. Ablation Strategy of AVNRTMake a correct diagnosis!!!Ablation
of slow or intermediate AVN1. Anatomic approach: P M A2.
Electrogram approach: small A, large V3. JT during RFHow to avoid
AV block?1. ablation during A pacing2. avoid ablation during SVT or
V pacing.3. You have only one second to stop RF!!! 31. JT under
during RF 32. Transient second degree AVB 33. Flat and horizontal
Kochs TriangleRAO LAO (Lee PC et al. Curr Opin Cardiol. 2009) 34.
Ablation Strategy of AVRT Make a correct diagnosis!!!Localization
of the APs: 12-lead ECG algorithm and intracardiac recordings.
Antegrade approach: for RT AP Retrograde approach: for LT AP1. V
site (subvalvular): small A, large V, stable ablation catheter2. A
site (ante- or retro-grade): larger A, unstable ablation catheter
35. Delta Wave in NSR(Chiang CE et al. AJC 1996) 36. Whats on the
other side 37. 38. Cases Discussion 39. Case 1VT, PSVT with RBBB or
preexcitated tachycardia? 40. RA burst + Isuprel induce SVTWhats
the mechanism of SVT? AVNRT with Wenkebach AV block then 1:1
conduction 41. S-F AVNRT 42. PSVT with LBBB 43. RVS1S2 induced PSVT
500 270 44. Retrograde-intermediate AVN or AP? AH=188 ms HA=158 ms
45. VPC terminate SVT: AVN or AP? 347 ms 347 ms 293 ms 46. V pacing
during SVT: AVN or AP?372 ms 350 ms Lower common pathway 47.
Mapping retrograde pathway and terminate SVT (after ablation of
antegrade SAVN) 48. RAO LAO Ablation ofAntegradeSAVN Ablation
ofretrogradeintermediateAVN 49. Case 2A 28 Y/O male fireman had
recurrent attacks of tachycardia during exercise RVOT-VT, PSVT with
LBBB or Preexcited tachycardia? 50. NSR (Intermittent
Preexcitation) AP location? 51. RVS1S1 350 ms 350 52. RVS1S1 340
msFavors AP Sudden VA block 340 53. RVS1S2 500/310 msF-S echo 54.
RAS1S2 Induced Tachycardia Wide QRS complex tachycardia: VT?, or
Preexcitated tachycardia? PSVT with LBBB 55. Wide QRS
TachycardiaTCL= 256 ms 56. Question? Whats the mechanism of Wide
QRScomplex tachycardia?VT? Preexcitated tachycardia? PSVT withLBBB?
PSVT with LBBB Whats the next step to D.D? 57. VPC terminate
tachycardiaWithout conduction to AVPCCan rule out AT 58. VOP
terminate tachycardia Sudden VA block The same A sequence No lower
common pathwayAVNRT is not likely 59. Initiation of NQRS
tachycardia 60. NQRS TachycardiaTCL= 244 ms shorter than SVT with
LBBB (256 ms)Favor left side AP? 61. VPC reset SVT248233His
refractory VPC 62. Ablation site: RPS 63. Success within 5
secondsRF on VA block 64. Immediate recurrence within 5RF off 65.
Ablation site 1: RPS 66. Success within 3 seconds VA block 67.
Immediate recurrence within 3 68. Ablation site 2: RPS 69. Ablation
site: LMS 70. Success within 5 secondsVA block 71. Ablation site 3:
LMS 72. Transient CAVB 73. PS APs (Chiang CE et al. Circulation
1996) 74. MS APs(Chang SL et al. JCE 2005) 75. Small & narrow P
wave RA & LA depolarization simultaneouslyTest A P wave in the
midpoint between the two QRS beatsDiagnosis: SF AVNRT with 2:1 AV
block 76. TestAT with 2:1 AV block?Whats the next step? 77. Test:
VOP 2:1 to 1:1 conduction 78.
