Anterograde His bundle activation during right ventricular overdrive pacing in supraventricular tachycardia

Abstract

Background Differentiation between atrioventricular nodal re‐entrant tachycardia (AVNRT), atrioventricular re‐entrant tachycardia (AVRT), and atrial tachycardia (AT) is often challenging during electrophysiology studies. This study compared the sensitivity and specificity of identifying anterograde His bundle activation during entrainment with commonly used right ventricular (RV) pacing maneuvers to differentiate between these types of supraventricular tachycardia (SVT). Methods Out of 112 consecutive patients with SVT, 90 (36 males [40%], age 37 ± 16 years) were prospectively studied. After entrainment during RV pacing, atrial response upon cessation of pacing, anterograde His activation during entrainment, stimulus‐atrial (SA), ventriculoatrial (VA) intervals, and post‐pacing interval minus tachycardia cycle length (PPI‐TCL) were determined. Ventricular extrastimulation during tachycardia and para‐Hisian pacing were performed. Results The final diagnosis was AVNRT in 54, AVRT in 33, and AT in 3 patients. Entrainment was achieved in 87(96%) patients. Anterograde His bundle activation predicted AVRT (sensitivity: 62.5%, specificity: 100%). PPI‐TCL ≥129 ms predicted AVNRT (sensitivity: 83%, specificity: 84%), as did SA‐VA value ≥85 ms (sensitivity: 91%, specificity: 87%). Atria were advanced during transition zone in 57% of AVRTs. Atrial pre‐excitation in response to progressively premature ventricular extrastimuli identified AVRT (sensitivity: 90%, specificity: 85%). Pre‐excitation index ≥87 ms identified AVNRT (sensitivity: 80%, specificity: 100%). Para‐Hisian pacing identified AVRT (sensitivity: 25%, specificity: 100%). Conclusion RV pacing maneuvers, applied in isolation, can misclassify a significant proportion of SVTs. Identifying anterograde His bundle activation during entrainment can complement other discriminators in differential diagnosis of SVT, with greatest sensitivity in septal and right‐sided accessory pathways.

Ventricular tachycardia originating from the His bundle: A case report

“…The atria and ventricles play important roles in atrioventricular node re-entry tachycardia and atrioventricular re-entry tachycardia[ 12 ]. The ECG of our patient showed that the atria and ventricles were separated, which excluded supra VT.…”

Right ventricular pacing maneuvers for the differential diagnosis of supraventricular tachycardia

“…We read the article "Anterograde His bundle activation during right ventricular overdrive pacing in supraventricular tachycardia" by Elbatran et al with interest. 1 We believe that their study is likely pacing. [2][3][4] These maneuvers are useful for the differential diagnosis of AVNRT, AVRT, and AT.…”

“…We read the article “Anterograde His bundle activation during right ventricular overdrive pacing in supraventricular tachycardia” by Elbatran et al with interest . We believe that their study is likely to form a valuable addition to the literature.…”

Response to right ventricular pacing maneuvers for the differential diagnosis of supraventricular tachycardia

“…The comments by Ozcan Celebi et al are insightful and raise the question of how to improve the detection of anterograde His bundle activation. Anterograde His bundle activation is an intracardiac manifestion of fusion . As a result, it can be easier to demonstrate when fusion occurs more distally within the ventricle below the level of the His bundle.…”

“…Placing closely spaced multielectrode catheters at the His position can enhance the yield of this manoeuvre, first by providing multiple His bundle recordings from which to assess anterograde His activation and second by suggesting the direction of activation of the His bundle and right bundle branch (proximal to distal with anterograde activation) and comparing it to activation during tachycardia.…”