1. Arrhythmia ECG
Tachycardia
林亮宇
台大醫院 科部內

2. Tachycardia
Surpa-ventricular tachycardia
Ventricular tachycardia
Ventricular fibrillation

3. 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)

4. 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

6. AVNRT: Slow-Fast (Common), Fast-Slow (Uncommon)
No “ P ” in Common Type, Clear “ P’ ” in Uncommon
Type

7. AV NODAL EXTENSIONSAV NODAL EXTENSIONS
CS OS
Anterior
extension Posterior
extension
Tricuspid
hinge

8. Pre-excitationPre-excitation

9. Anatomical locations of Right vs. Left Accessory Pathways

10. Pre-excitationPre-excitation

11. Wide-Complex Tachycardia, r/o VT
Sinus Rhythm AVRT, Antidromic

12. Ebstein’s Anomaly, WPW Syndrome

13. Avoid CCB, BB, digoxin

14. PSVT 之電生理分類 ：
3. 與 atrial muscle 有關者
Atrial tachycardia
Atrial flutter
Atrial fibrillation

15. “AT” in A SSS Patient :
Focal AT in RA

16. Atrial flutter

17. Typical Atrial Flutter: circuit & ablation
IVCO-TA
isthmus

18. Focal to chaotic Atrial Fibrillation
Cont’d.

19. 陣發 持續

20. Circumferential PV isolation by RFCA
Pappone C, Circulation 2000.

21. 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
Cardioversion
Low perfusion
AF, Afib within 48 hrs (TEE/anticoagulant)
Prevention of embolism AF, Afib
RFCA for AVNRT, AVRT, AT, AF and Afib?
Management of SVT

22. Ventricular tachycardia
Idiopathic VT
-From RVOT
-From LV inferioapical septal region: ILVT
Organic VT
CAD
CHF
Cardiomyopathy: HCM, DCM,

23. VTVT

24. 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

25. VT: AV dissociationVT: AV dissociation

26. VT:VT:
positive &positive &
negativenegative
concordanceconcordance

27. Capture beatCapture beat

28. Idiopathic Ventricular TachycardiaIdiopathic Ventricular Tachycardia
DefinitionDefinition : ventricular arrhythmia that: ventricular arrhythmia that
originate in hearts without structuraloriginate in hearts without structural
diseasedisease
Right/ left ventricular outflow tract VTRight/ left ventricular outflow tract VT
(Adenosine- sensitive VT)(Adenosine- sensitive VT)
Left ventricular fascicular tachycardiaLeft ventricular fascicular tachycardia
(Verapamil- sensitive VT)(Verapamil- sensitive VT)

29. • MostMost
common:common:
RVOT,RVOT,
LBBB andLBBB and
inferior axisinferior axis
• LessLess
common:common:
LVOT:LVOT:
RBBB andRBBB and
inferior axisinferior axis

30. Idiopathic Left Ventricular Tachycardia
A-V Dissociation, RBBB and Superior Axis Favors VT,

31. Idiopathic Left Ventricular Tachycardia
A-V Dissociation, RBBB and Superior Axis Favors VT,

32. 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

33. Postulated Reentry Circuit in Post-Infarct VT (Stevenson WG, 1993)

34. Torsade de Pointes (TdP)
Long QT related
Early after depolarization (EAD)
R on T
Congenital or acquired (mostly drug)-

35. Female, 22 y/o

36. Torsade de PointesTorsade de Pointes

37. Management of TdP
Overdrive pacing
Isoproterenol
MgSO4
Beta-blockers
Remove offending agents
anti-histamine, antifungal, macrolide, AAD

38. With Structural heart disease
HCM, ARVD
Without structural heart disease
Long (short) QT syndrome: NA, KChannelopathy
Brugada syndrome: Na channel defect
Catecholaminergic polymoprhic VT: Ryanodine Rdefect
Hereditary SCD syndrome

39. Antzelevitch et al, JACC 2003; 41: 1665-71
Brugada Syndrome

40. Male, 32 y/o, Recurrent Seizures
Brugada Syndrome : VF

41. V1
II
V5
aVF
V4
V6
CPVT Catecholaminergic Polymorphic Ventricular Tachycardia
Ryanodine receptor ( RyR2 ) mutation, rise of Ca i

42. Bi-directional VT: digoxin intoxication

43. Ventricular FibrillationVentricular Fibrillation

44. ICDindication forSCDprevention in:
 Post-Infarction
 Cardiomyopathy, ARVD
 Heart failure
 Brugada /LQTS/CPVT/SQTS
 Idiopathic VF

45. Thank you for your
attention