A Technique for the Rapid Diagnosis of Wide Complex Tachycardia with 1:1 AV Relationship in the Electrophysiology Laboratory

AbdelWahab, Amir; Gardner, Martin J.; Basta, Magdy N.; Parkash, Ratika; Khan, Aamir Hameed; Sapp, John L.

doi:10.1111/j.1540-8159.2009.02308.x

Cited by 20 publications

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References 17 publications

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“…Abdelwahab et al reported that atrial overdrive pacing during the tachycardia is useful for these differentiations [2]. They demonstrated that the presence of both a narrowing of the QRS complex during the atrial overdrive pacing and an AVVA response upon cessation of atrial overdrive pacing are suggestive of ventricular tachycardia as the mechanism of WCT.…”

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confidence: 99%

“…However, a WCT with a 1:1 AV relationship necessitates careful observation and EP techniques to clarify the mechanism underlying the tachycardia. Several techniques have been described for determining the mechanism underlying tachycardia [1][2][3]. Shortening of the HV interval or a change of the His and RBB activation sequence will favor ventricular tachycardia (VT) or pre-excited supraventricular tachycardia (SVT).…”

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confidence: 99%

“…Shortening of the HV interval or a change of the His and RBB activation sequence will favor ventricular tachycardia (VT) or pre-excited supraventricular tachycardia (SVT). A shorter His-atrial (HA) interval during tachycardia than during RV pacing is consistent with AVNRT with aberration or bystander accessory pathway (AP) [1].Abdelwahab et al reported that atrial overdrive pacing during the tachycardia is useful for these differentiations [2]. They demonstrated that the presence of both a narrowing of the QRS complex during the atrial overdrive pacing and an AVVA response upon cessation of atrial overdrive pacing are suggestive of ventricular tachycardia as the mechanism of WCT.…”

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Wide QRS complex tachycardia with a 1:1 AV relationship

Yamane

2012

Journal of Arrhythmia

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A 45-year-old man was referred for the management of sudden-onset tachycardia. He had experienced 3 episodes of palpitation attacks, lasting for a couple of hours each, during the last 6 months. A regular, wide QRS complex tachycardia (WCT) at 150 beats/min with a prominent retrograde P wave on the surface electrocardiogram (ECG) was documented during the last attack, which was terminated by drip infusion of pilsicainide administered at another hospital. He did not experience loss of consciousness or dizziness during his palpitation attacks. The findings of other investigations, including physical examination, two-dimensional echocardiography, chest radiography, and laboratory tests, were unremarkable.Cardiac electrophysiological study (EPS) was performed after written informed consent was obtained. Venous access was performed via the right femoral and subclavian veins. Three 5-French quadripolar catheters were advanced to the right ventricular apex, right atrial appendage, and His-bundle region. A 5-French decapolar catheter was placed within the coronary sinus (CS), with a proximal electrode located at its ostium.During the EPS study, a WCT with a cycle length of 330 ms was induced by a ventricular extrastimulus. The morphology of the 12-lead ECG was consistent with that of the clinical tachycardia and showed the right bundlebranch block pattern and left axis deviation. Intracardiac ECG showed a 1:1 atrioventricular (A-V) relationship (Fig. 1). What is the cause of this tachycardia? CommentaryOur first impression in this case was AV nodal reentry tachycardia (AVNRT) with aberrant ventricular conduction, since both right atrium and ventricle were activated almost simultaneously after the sharp His-potential. A radio frequency (RF) energy application was attempted at a slowpathway lesion, which did not generate junctional rhythm or affect the inducibility of the tachycardia.During EPS, the differential diagnosis of the WCT between the supraventricular and ventricular origin is not difficult if A-V dissociation is observed. However, a WCT with a 1:1 AV relationship necessitates careful observation and EP techniques to clarify the mechanism underlying the tachycardia. Several techniques have been described for determining the mechanism underlying tachycardia [1][2][3]. Shortening of the HV interval or a change of the His and RBB activation sequence will favor ventricular tachycardia (VT) or pre-excited supraventricular tachycardia (SVT). A shorter His-atrial (HA) interval during tachycardia than during RV pacing is consistent with AVNRT with aberration or bystander accessory pathway (AP) [1].Abdelwahab et al. reported that atrial overdrive pacing during the tachycardia is useful for these differentiations [2]. They demonstrated that the presence of both a narrowing of the QRS complex during the atrial overdrive pacing and an AVVA response upon cessation of atrial overdrive pacing are suggestive of ventricular tachycardia as the mechanism of WCT.In this case, transient ventricular capture during overdrive atrial pa...

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Wide QRS complex tachycardia with a 1:1 AV relationship

Yamane

2012

Journal of Arrhythmia

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“…In this issue of the Journal , AbdelWahab et al have proposed a new diagnostic maneuver in the EP laboratory to elucidate the diagnosis of stable sustained WCT with 1:1 AV relationship 3 . The authors performed atrial overdrive pacing (AOD) from the right atrium in left bundle branch block (LBBB) morphology WCT or coronary sinus in right bundle branch block (RBBB) morphology WCT during tachycardia and evaluated the results as follows: (1) change in QRS morphology during atrial pacing and (2) the first return electrogram after cessation of pacing (atrium response [AVA] vs ventricle response [AVVA]).…”

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“…The authors present an example of a long AV interval during AOD (Fig. 6) that gives a pseudo‐AVVA response in a patient with WCT due to SVT with aberrancy 3 …”

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Electrophysiological Diagnosis of Wide Complex Tachycardia

Badhwar

Scheinman

2009

Pacing Clinical Electrophis

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The diagnosis of wide complex tachycardia (WCT) has always been a challenge for clinicians. The differential diagnosis includes ventricular tachycardia (VT), supraventricular tachycardia (SVT) with aberrant conduction, and preexcited tachycardia in patients with accessory pathways. Electrophysiology study (EPS) has been used as the gold standard with the demonstration of His-ventricular (HV) dissociation confirming a diagnosis of VT. However, WCT with 1:1 atrioventricular (AV) relationship can be a diagnostic challenge; the differential diagnosis includes VT, SVT with aberrancy, and antidromic SVT including atrioventricular re-entry tachycardia (AVRT) or atriofascicular tachycardia. Various diagnostic maneuvers in the EP laboratory to ascertain the diagnosis include measurement of HV during tachycardia (short or negative HV in VT and preexcited SVT), response to adenosine, introduction of premature atrial extrastimuli during tachycardia, and measurement of His-atrial (HA) during tachycardia and during right ventricular pacing. 1,2 Despite these maneuvers, the differentiation of VT from SVT (especially antidromic SVT) can be a diagnostic dilemma.In this issue of the Journal, AbdelWahab et al. have proposed a new diagnostic maneuver in the EP laboratory to elucidate the diagnosis of stable sustained WCT with 1:1 AV relationship. 3 The authors performed atrial overdrive pacing (AOD) from the right atrium in left bundle branch block (LBBB) morphology WCT or coronary sinus in right bundle branch block (RBBB) morphology WCT during tachycardia and evaluated the results as follows: (1) change in QRS morphology during atrial pacing and (2) the first return electrogram after cessation of pacing (atrium response [AVA] vs ventricle response [AVVA]). They hypothesized that AOD would change the QRS complex due to antegrade capture during VT and that cessation of atrial pacing would lead to another ventricular response after AVVA since the atrium is passively being driven by the ventricle. On the conAddress for reprints: Nitish Badhwar, M.B.B.S.trary, AOD would not change the QRS morphology during SVT and the response after cessation of atrial pacing would be AVA as the atrium is actively participating in the circuit. The results showed that a change in QRS morphology during AOD and AVVA response after AOD clearly differentiated the patients with VT from those with SVT and antidromic AVRT. The authors conclude that this is a rapid diagnostic maneuver that can easily differentiate VT from SVT in patients with WCT and 1:1 AV relationship.This maneuver is the reverse of ventricular overdrive pacing (VOD) during narrow complex tachycardia that is frequently used to differentiate atrial tachycardia (AT) showing a VAAV response from AVRT and AVNRT that show VAV response at the cessation of pacing. 4 The authors have given very clear illustrations in support of their hypothesis. It is important to ensure that AOD does not terminate tachycardia. The interval from paced atrial complex to the reset ventricular complex should be calculat...

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Transient narrowing of a wide QRS tachycardia. What is the mechanism?

Ribes

Martínez-Brotons

Ferrero-de-Loma-Osorio

et al. 2020

Journal of Arrhythmia

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K E Y W O R D S : accessory pathway, concealed conduction, orthodromic atrioventricular reentrant tachycardia, wide QRS tachycardia | C A S E PRE S ENTATI ONA 56-year-old male was admitted to the Emergency Department for palpitations with no other background. The electrocardiogram (ECG) showed a regular wide QRS tachycardia with left bundle branch block (LBBB) like in morphology at 200 beats per minute (bpm). A rapid bolus of adenosine interrupted the tachycardia and sinus rhythm was restored. During the electrophysiology study, the tachycardia was spontaneously induced (Figure 1). What is the mechanism of the switch from a broad complex to a narrow complex tachycardia? | D ISCUSS I ONAs shown in Figure 1, R-R intervals during LBBB-like beats are longer than R-R intervals while narrow complexes. Such observation, rules out phase 3 and phase 4 block phenomenon. We hypothesize that a temporary shortening of the effective refractory period (ERP) of the LBBB could lead to a conduction over both branches, with a narrow complex.For the electrophysiology study, two tetrapolar diagnostic catheters were placed in the right ventricule apex and in the His bundle region. Despite many attempts to reach de coronary sinus, it was impossible to locate a diagnostic catheter inside it from a femoral approach, probably being an hypertrophic Thebesian valve the underlying cause. In Figure 2A, we can see the intracardiac tracing showing an AV 1:1 relation. The progressive narrowing of the QRS with subsequent shortening in the tachycardia cycle length which predicts changings in the next A-A interval,1 proves the dependence of the His-Purkinje system or ventricular myocardium in the tachycardia circuit.Accordingly to these findings, the differential to this tachycardia would be a ventricular tachycardia with ventriculoatrial (VA) conduction or an atrioventricular reentrant tachycardia (AVRT), and hence, the diagnostic clue would be the His Bundle (HB) activation pattern.This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

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A Technique for the Rapid Diagnosis of Wide Complex Tachycardia with 1:1 AV Relationship in the Electrophysiology Laboratory

Abstract: The response to atrial overdrive pacing during WCT with 1:1 AV relationship can rapidly diagnose or rule out VT as a mechanism of tachycardia.

Cited by 20 publications

References 17 publications

Wide QRS complex tachycardia with a 1:1 AV relationship

Wide QRS complex tachycardia with a 1:1 AV relationship

Electrophysiological Diagnosis of Wide Complex Tachycardia

Transient narrowing of a wide QRS tachycardia. What is the mechanism?

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