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

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