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Differentiation between AVNRT and AVRT_advanced lecture
1. Advanced AVNRT and AVRT
With differentiation
Advanced EP Training
(ไธญ่ฏๆฐๅๅฟ๏ง้ซๅญธๆ)
่ฌๆ้ ้ซๅธซ
ๅฐ๏ฅฃ้ซๅญธๅคงๅญธ้ซๅญธ็ณปๅฏๆๆ
่ฌ่ณ้ซ้ขๅฟ่ๅ ง็งไธปไปป
April 24, 2011 ๆผๅฐ๏ฅฃๅ้้ฃฏๅบ
2. Supraventricular tachycardia (SVT)
โข Etiology: (่บ๏ฅฃๆฆฎ็ธฝๅไธ๏ฆ็ถ้ฉ)
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%
5. Short RP SVT
1. Slow-Fast AVNRT:
No apparent retrograde P wave: 50%
Pseudo Rโ in V1 or pseudo-S in inferior
leads: 50%
2. Orthodromic AVRT: 70 ms<RP<PR
The presence of delta wave in NSR.
3. AT with PR prolongation: the presence of
AV block favors AT.
14. Long RP SVT
1. 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.
16. Favors AVNRT
1. 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
โข Antegrade SAVN: AH jump > 50 ms
โข Continuous curve AVNRT
โข Retrograde SAVN:
1.Long VA interval
2.CSO-A earliest.
โข Retrograde intermediate AVN:
1.Intermediate VA interval
2.His-A and CSO-A both earlier
โข AVNRT with retrograde eccentric
activation
22. Favors AVRT
1. 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.
25. His refractory VPC
โข 35-55 ms before the His deflection.
โข Advance the following A: AVRT
โข VPC without conducting to atrium but
terminate the SVT: rule out AT.
โข VPC from the sites other than RVA:
LV: for left side APs
RVOT: for septal APs
27. VOP entrains the SVT
โข VOP could not entrain SVT: AT
โข The same atrial activation sequence:
AVNRT or AVRT
The different atrial activation sequence: AT
โข The presence of lower common pathway:
AVNRT is more likely.
โข The presence of V-A-A-V response: AT
โข The presence of V-A-V response: favors
AVNRT or AVRT.
28. VOP during SVT
A A
V
V
AT
1. 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)
30. Ablation Strategy of AVNRT
โข Make a correct diagnosis!!!
โข Ablation of slow or intermediate AVN
1. Anatomic approach: P M A
2. Electrogram approach: small A, large V
3. JT during RF
โข How to avoid AV block?
1. ablation during A pacing
2. avoid ablation during SVT or V pacing.
3. You have only one second to stop RF!!!
33. Flat and horizontal Kochโs Triangle
RAO LAO
(Lee PC et al. Curr Opin Cardiol. 2009)
34. Ablation Strategy of AVRT
โข Make a correct diagnosis!!!
โข Localization of the APs: 12-lead ECG
algorithm and intracardiac recordings.
โข Antegrade approach: for RT AP
โข Retrograde approach: for LT AP
1. V site (subvalvular): small A, large V, stable
ablation catheter
2. A site (ante- or retro-grade): larger A, unstable
ablation catheter
56. Question?
โข Whatโs the mechanism of Wide QRS
complex tachycardia?
VT? Preexcitated tachycardia? PSVT with
LBBB? PSVT with LBBB
โข Whatโs the next step to D.D?
76. Small & narrow P wave RA & LA depolarization simultaneously
Test A P wave in the midpoint between the two QRS beats
Diagnosis: SF AVNRT with 2:1 AV block