Differentiating Junctional Tachycardia and Atrioventricular Node Re-Entry Tachycardia Based on Response to Atrial Extrastimulus Pacing

Padanilam, Benzy J.; Manfredi, Joseph A.; Steinberg, Leonard A.; Olson, Jeff; Fogel, Richard I.; Prystowsky, Eric N.

doi:10.1016/j.jacc.2008.08.030

Cited by 123 publications

(110 citation statements)

References 7 publications

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“…21,22 Atrial extrastimulation and overdrive pacing were not systematically performed during tachycardia to exclude junctional tachycardia or assess VA linking. [23][24][25] However, because focal junctional tachycardia associated with retrograde conduction over the SP is extremely rare and none of our tachycardias exhibited nonreentrant behavior (eg, warm-up/cool-down phenomena, initiation after a spontaneous junctional complex), we are confident of our diagnoses. In addition, the value of VA linking in long RP tachycardias is unclear because VA intervals can vary significantly during atypical ORT and AVNRT because of decremental conduction over the AP and SP, respectively.…”

Section: Limitationsmentioning

confidence: 77%

Electrophysiological Features Differentiating the Atypical Atrioventricular Node–Dependent Long RP Supraventricular Tachycardias

Frisch

Pavri

et al. 2013

Circ: Arrhythmia and Electrophysiology

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E stablishing the diagnosis of an atypical atrioventricular (AV) node-dependent long RP supraventricular tachycardia (SVT) can be difficult. Standard diagnostic criteria are lacking and often extrapolated from pacing maneuvers applied to the more common short RP SVT. Long RP SVTs involving concealed nodofascicular (NF) accessory pathways (AP) are particularly rare with descriptions limited to isolated case reports. [1][2][3][4] Prolonged conduction over the slow pathway (SP) of the AV node or a decremental AP after entrainment from the ventricle can produce A-A-V patterns that might be mistaken for atrial tachycardia (AT). 5 In addition, slow AP conduction after entrainment of an atypical orthodromic reciprocating tachycardia (ORT) can generate long postpacing intervals (PPI) that cause misdiagnosis of AV nodal reentrant tachycardia (AVNRT), despite correction for delay in the AV node (cPPI). [5][6][7] This study sought to evaluate the electrophysiological features and criteria differentiating the 4 atypical AV node-dependent long RP SVTs: atypical AVNRT, atypical AVNRT with a concealed, bystander NF AP (atypical AVNRT/NF AP), ORT using a concealed, slowly conducting, decremental AV AP (also called the permanent form of junctional reciprocating tachycardia [PJRT]), and ORT using a concealed NF AP (also called NF reentrant tachycardia [NFRT]

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Section: Limitationsmentioning

confidence: 77%

Electrophysiological Features Differentiating the Atypical Atrioventricular Node–Dependent Long RP Supraventricular Tachycardias

Frisch

Pavri

et al. 2013

Circ: Arrhythmia and Electrophysiology

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“…In a recent study, the average ⌬HA interval in AVNRT was Ϫ10 ms, although positive values were encountered. 48 Padanilam et al 49 described the use of premature atrial stimuli for differential diagnosis of slow-fast AVNRT and nonreentrant junctional tachycardia. An atrial premature complex that is timed to His refractoriness and advances the His electrogram of the subsequent cycle indicates that Figure 5.…”

Section: Avnrt Versus Nonreentrant Junctional Tachycardiasmentioning

confidence: 99%

Atrioventricular Nodal Reentrant Tachycardia

2010

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A trioventricular nodal reentrant tachycardia (AVNRT) represents the most common regular supraventricular arrhythmia in humans. 1 The precise anatomic site and nature of the pathways involved have not yet been established, and several attempts to provide a reasonable hypothesis based on anatomic or anisotropic models have been made. 2 There has been considerable evidence that the right and left inferior extensions of the human atrioventricular (AV) node and the atrionodal inputs they facilitate may provide the anatomic substrate of the slow pathway, and a comprehensive model of the tachycardia circuit for all forms of AVNRT based on the concept of atrionodal inputs has been proposed. 2 Still, however, the circuit of AVNRT remains elusive. Recently, time-honored conventional schemes for the diagnosis and classification of the various forms of the arrhythmia have been refuted in part by evolving evidence. Recognition of the various types of AVNRT is important, however, to expedite diagnosis and allow implementation of appropriate ablation therapy without complications. We present an update on AVNRT with a particular emphasis on electrophysiological criteria used for the differential diagnosis of regular, supraventricular tachycardias. ECG PresentationTypically, AVNRT is a narrow-complex tachycardia, ie, QRS duration Ͻ120 ms, unless aberrant conduction, which is usually of the right bundle-branch type, or a previous conduction defect exists. Tachycardia-related ST depression and RR-interval variation may be seen. RR alternans in AVNRT has been attributed to the proposed model of a figure of 8 reentry with continuous crossing over of antegrade activation through an inferior input to the contralateral superior input via the node. 2 In the typical form of AVNRT (slow-fast), abnormal (retrograde) PЈ waves are constantly related to the QRS and in the majority of cases are indiscernible or very close to the QRS complex (RPЈ/RR Ͻ0.5). Thus, PЈ waves are either masked by the QRS complex or seen as a small terminal PЈ wave that is not present during sinus rhythm (Figure 1). In the atypical form of AVNRT (fast-slow), PЈ waves are clearly visible before the QRS, ie, RPЈ/PЈR Ͼ0.75 (Figure 2), denoting a "long RP tachycardia," and are negative in leads II, III, aVF, and V 6 but positive in V 1 . PЈ waves are shallow in the inferior leads in the rare form of anterior fast-slow AVNRT. 3 Although AV dissociation is usually not seen, it can occur because neither the atria or the ventricles are necessary for the reentry circuit. If the tachycardia is initiated by atrial ectopic beats, the initial (ectopic) PЈ wave usually differs from the subsequent (retrograde) PЈ waves (Figure 1).

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“…They found that a delta HA that was positive diagnosed JT with a sensitivity of 89% and a specificity of 83%; conversely, a negative delta HA diagnosed AVNRT with a sensitivity of 83%. A study by Padanilam et al 6 emphasized the significance of the different response to PACs during tachycardia. They postulated that any perturbation of the subsequent His during tachycardia, including advancement or delay, or termination of the tachycardia itself after a PAC delivered within the refractoriness of the His bundle indicates anterograde conduction via SP and can effectively exclude JT.…”

Section: Discussionmentioning

confidence: 99%

Differentiating Atrioventricular Nodal Re-Entrant Tachycardia From Junctional Tachycardia

Chen

Shehata

Cingolani

et al. 2015

Circ: Arrhythmia and Electrophysiology

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T ypical atrioventricular nodal re-entrant tachycardia (AVNRT) is the most common supraventricular tachycardia; however, junctional tachycardia (JT) is rare and occurs mostly in children or during infusion of isoproterenol. 1,2 Distinguishing between these arrhythmias can often be challenging during electrophysiology testing. They share many common characteristics, including similar intracardiac activation patterns, similar sites of earliest activation, and typical occurrence of a His bundle deflection before the atrial and ventricular electrograms. Slow pathway (SP) modification has evolved as the first-line treatment for AVNRT with acute success rates of 95% to 98% 3,4 ; however, catheter ablation of JT has lower success rates and a higher rate of atrioventricular block.5 Previous studies have suggested that premature atrial contractions (PACs) or atrial overdrive pacing can rapidly differentiate AVNRT from JT. 2,6Editor's Perspective see p 236 Case PresentationA 72-year-old woman with a history of paroxysmal supraventricular tachycardia that was refractory to medical therapy underwent catheter ablation. During the procedure, baseline AA interval during sinus rhythm, AH interval, and HV interval were 610, 80, and 38 ms ( Figure 1A), respectively. Narrow QRS tachycardia was induced by atrial burst pacing (320 ms; Figure 1B), which was felt to be most consistent with slow/ fast AVNRT (cycle length, 380 ms; AH, 340 ms; HA, 40 ms) based on the characteristics of induction with a critically long AH interval and the response to right ventricular overdrive pacing ( Figure 1B and 1C). SP modification was performed and guided by intracardiac electrograms and fluoroscopic landmarks. After SP modification, a tachycardia spontaneously initiated during infusion of isoproterenol with a dosage of 1 μg/min at a cycle length of 540 ms, with HA and AH intervals of 40 and 500 ms, respectively, as illustrated in Figure 2A. The tachycardia could be terminated by rapid atrial pacing or PACs and would spontaneously initiate after a few sinus tachycardia beats (Figure 2A). Figure 2B demonstrates the spontaneous onset of tachycardia at faster sweep speed with initial shortening of the HH interval to 450 ms, followed by tachycardia with the HH interval of 540 ms.PACs were introduced throughout the diastolic interval beginning at 10 ms shorter than the tachycardia cycle length until the loss of atrial capture or tachycardia was terminated ( Figure 2C). A PAC that advanced the immediate His by 50 ms resulted in delaying the subsequent His by 50 ms ( Figure 2D). However, a later PAC advanced the immediate His by 40 ms, and there was no change in the following HH interval ( Figure 2E). A later PAC delivered during His refractoriness advanced the following His by 15 ms, indicating that the mechanism of tachycardia was AVNRT ( Figure 2F). This was confirmed multiple times with late-coupled PACs advancing the subsequent His activation without affecting the immediate His. Further ablation at the SP region was performed, and subsequently, no ta...

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Differentiating Junctional Tachycardia and Atrioventricular Node Re-Entry Tachycardia Based on Response to Atrial Extrastimulus Pacing

Abstract: The response to PACs during tachycardia can distinguish JT and AVNRT with 100% specificity in adult patients.

Cited by 123 publications

References 7 publications

Electrophysiological Features Differentiating the Atypical Atrioventricular Node–Dependent Long RP Supraventricular Tachycardias

Electrophysiological Features Differentiating the Atypical Atrioventricular Node–Dependent Long RP Supraventricular Tachycardias

Atrioventricular Nodal Reentrant Tachycardia

Differentiating Atrioventricular Nodal Re-Entrant Tachycardia From Junctional Tachycardia

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