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Spontaneous Variation of Ventriculo-Atrial Interval after Tachycardia Induction: Determinants and Usefulness in the Diagnosis of Supraventricular Tachycardias with Long Ventriculoatrial Interval. J Clin Med 2023; 12:jcm12020409. [PMID: 36675339 PMCID: PMC9864055 DOI: 10.3390/jcm12020409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 12/26/2022] [Accepted: 12/31/2022] [Indexed: 01/06/2023] Open
Abstract
Background: Determining the mechanism of supraventricular tachycardias with prolongedP ventriculoatrial (VA) intervals is sometimes a challenge. Our objective is to analyse the determinants, time course and diagnostic accuracy (atypical atrioventricular nodal reentrant tachycardias [AVNRT] versus orthodromic reentrant tachycardias through an accessory pathway [ORT]) of spontaneous VA intervals variation in patients with narrow QRS tachycardias and prolonged VA. Methods: A total of 156 induced tachycardias were studied (44 with atypical AVNRT and 112 with ORT). Two sets of 10 measurements were performed for each patient—after tachycardia induction and one minute later. VA and VV intervals were determined. Results: The difference between the longest and the shortest VA interval (Dif-VA) correlates significantly with the diagnosis of atypical AVNRT (C coefficient = 0.95 and 0.85 after induction and at one minute, respectively; p < 0.001). A Dif-VA ≥ 15 ms presents a sensitivity and specificity for atypical AVNRT of 50% and 99%, respectively after induction, and of 27% and 100% one minute later. We found a robust and significant correlation between the fluctuations of VV and VA intervals in atypical AVNRTs (Coefficient Rho: 0.56 and 0.76, after induction and at one minute, respectively; p < 0.001 for both) but not in ORTs. Conclusions: The analysis of VA interval variability after induction and one minute later correctly discriminates atypical AVNRT from ORT in almost all cases.
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Hadid C, Celano L, Di Toro D, Antezana-Chavez E, Gallino S, Iralde G, Calvo D, Ávila P, Atea L, Gonzalez S, Maldonado S, Labadet C. Variability of the VA interval at tachycardia induction: a simple method to differentiate orthodromic reciprocating tachycardia from atypical atrioventricular nodal reentrant tachycardia. J Interv Card Electrophysiol 2022; 66:637-645. [PMID: 36152135 DOI: 10.1007/s10840-022-01376-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Accepted: 09/13/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND The differential diagnosis between orthodromic atrioventricular reentry tachycardia (AVRT) and atypical AV nodal reentrant tachycardia (aAVNRT) is sometimes challenging. We hypothesize that aAVNRTs have more variability in the retrograde conduction time at tachycardia onset than AVRTs. METHODS We aimed to assess the variability in retrograde conduction time at tachycardia onset in AVRT and aAVNRT and to propose a new diagnostic tool to differentiate these two arrhythmia mechanisms. We measured the VA interval of the first beats after tachycardia induction until it stabilized. The difference between the maximum and minimum VA intervals (∆VA) and the number of beats needed for the VA interval to stabilize was analyzed. Atrial tachycardias were excluded. RESULTS A total of 107 patients with aAVNRT (n = 37) or AVRT (n = 64) were included. Six additional patients with decremental accessory pathway-mediated tachycardia (DAPT) were analyzed separately. All aAVNRTs had VA interval variability. The median ∆VA was 0 (0 - 5) ms in AVRTs vs 40 (21 - 55) ms in aAVNRTs (p < 0.001). The VA interval stabilized significantly earlier in AVRTs (median 1.5 [1 - 3] beats) than in aAVNRTs (5 [4 - 7] beats; p < 0.001). A ∆VA < 10 ms accurately differentiated AVRT from aAVNRT with 100% of sensitivity, specificity, and positive and negative predictive values. The stabilization of the VA interval at < 3 beats of the tachycardia onset identified AVRT with sensitivity, specificity, and positive and negative predictive values of 64.1%, 94.6%, 95.3%, and 60.3%, respectively. A ∆VA < 20 ms yielded good diagnostic accuracy for DAPT. CONCLUSIONS A ∆VA < 10 ms is a simple and useful criterion that accurately distinguished AVRT from atypical AVNRT. Central panel: Scatter plot showing individual values of ∆VA in atypical AVNRT and AVRT. Left panel: induction of atypical AVNRT. The VA interval stabilizes at the 5th beat and the ∆VA is 62 ms (maximum VA interval: 172 ms - minimum VA interval: 110 ms). Right panel: induction of AVRT. The tachycardia has a fixed VA interval from the first beat. ∆VA is 0 ms.
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Affiliation(s)
- Claudio Hadid
- Hospital General de Agudos Dr. Cosme Argerich, Pi y Margall 750, 1155, Ciudad Autónoma de Buenos Aires, Argentina. .,Hospital Universitario CEMIC, Ciudad Autónoma de Buenos Aires, Argentina. .,Sanatorio Garat, Concordia, Entre Ríos, Argentina. .,Cardiovascular Chivilcoy, Chivilcoy, Buenos Aires, Argentina.
| | - Leonardo Celano
- Hospital General de Agudos Dr. Cosme Argerich, Pi y Margall 750, 1155, Ciudad Autónoma de Buenos Aires, Argentina.,Hospital Universitario CEMIC, Ciudad Autónoma de Buenos Aires, Argentina
| | - Darío Di Toro
- Hospital General de Agudos Dr. Cosme Argerich, Pi y Margall 750, 1155, Ciudad Autónoma de Buenos Aires, Argentina.,Hospital Universitario CEMIC, Ciudad Autónoma de Buenos Aires, Argentina
| | - Edgar Antezana-Chavez
- Hospital General de Agudos Dr. Cosme Argerich, Pi y Margall 750, 1155, Ciudad Autónoma de Buenos Aires, Argentina
| | | | - Gustavo Iralde
- Cardiovascular Chivilcoy, Chivilcoy, Buenos Aires, Argentina
| | - David Calvo
- Arrhythmia Unit, Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria de Asturias, Oviedo, Spain
| | - Pablo Ávila
- Cardiology Department, Hospital General Universitario Gregorio Marañon, Instituto de Investigación Sanitaria Gregorio Marañon, Madrid, Spain.,Centre for Biomedical Research in Cardiovascular Disease Network (CIBERCV), Madrid, Spain
| | | | | | | | - Carlos Labadet
- Hospital General de Agudos Dr. Cosme Argerich, Pi y Margall 750, 1155, Ciudad Autónoma de Buenos Aires, Argentina.,Hospital Universitario CEMIC, Ciudad Autónoma de Buenos Aires, Argentina
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Kaneko Y, Nakajima T, Tamura S, Hasegawa H, Kobari T, Iizuka T, Kurabayashi M. Superior-Type Fast-Slow Atrioventricular Nodal Reentrant Tachycardia Phenotype Mimicking the Slow-Fast Type. Circ Arrhythm Electrophysiol 2020; 13:e008732. [PMID: 33000970 DOI: 10.1161/circep.120.008732] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Superior-type fast-slow (sup-F/S-) atrioventricular nodal reentrant tachycardia (AVNRT) is a rare AVNRT variant using a superior slow pathway (SP) as the retrograde limb. Its intracardiac appearance, characterized by a short atrio-His (AH) interval and the earliest site of atrial activation in the His-bundle, is an initial indicator for making a diagnosis. METHODS Among 22 consecutive patients with sup-F/S-AVNRT, 3 (age, 68-81 years) patients had an apparent slow-fast (S/F-) AVNRT characterized by a long AH interval and the earliest site of atrial activation in or superior to the His-bundle region (tachy-long-AH). RESULTS The diagnosis of sup-F/S-AVNRT was based on the standard criteria in 2 patients and on the occurrence of Wenckebach-type atrioventricular block during tachycardia, which was attributable to a block at the lower common pathway (LCP) below the circuit of the AVNRT, detected owing to the lower common pathway potentials, in one patient. As with the typical S/F-AVNRT, tachy-long-AH was induced after a jump in the AH interval. In contrast to typical S/F-AVNRT, fluctuation in the ventriculoatrial interval was observed during the tachy-long-AH. Ventricular overdrive pacing was unable to entrain or terminate the tachy-long-AH. Moreover, the tachy-long-AH reciprocally transited to/from sup-F/S-AVNRT spontaneously or was triggered by ventricular contractions while the atrial cycle length and earliest site of atrial activation remained unchanged. Both tachycardias were cured by ablation at a single site in the right-side para-Hisian region of 2 patients and the noncoronary aortic cusp of one patient. Collectively, the essential circuit of both tachycardias was identical, and the tachy-long-AH was diagnosed as another phenotype of sup-F/S-AVNRT accompanied by sustained antegrade conduction via another bystander slow pathway breaking through the His-bundle owing to the repetitive antegrade block at the lower common pathway, thus representing a long AH interval during the ongoing sup-F/S-AVNRT. CONCLUSIONS An unknown sup-F/S-AVNRT phenotype exists that apparently mimics the typical S/F-AVNRT and is also an unknown subtype of apparent S/F-AVNRT.
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Affiliation(s)
- Yoshiaki Kaneko
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Tadashi Nakajima
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Shuntaro Tamura
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Hiroshi Hasegawa
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Takashi Kobari
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Takashi Iizuka
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Masahiko Kurabayashi
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
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Kaneko Y, Nakajima T, Irie T, Ota M, Iijima T, Iizuka T, Kurabayashi M. An Abrupt Change in the Atrio-His Interval during Long RP Tachycardia: What Is the Underlying Mechanism? PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2015; 39:190-3. [PMID: 26449818 DOI: 10.1111/pace.12763] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 10/01/2015] [Accepted: 10/04/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Yoshiaki Kaneko
- Department of Medicine and Biological Science, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Tadashi Nakajima
- Department of Medicine and Biological Science, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Tadanobu Irie
- Department of Medicine and Biological Science, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Masaki Ota
- Department of Medicine and Biological Science, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Takafumi Iijima
- Department of Medicine and Biological Science, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Takashi Iizuka
- Department of Medicine and Biological Science, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Masahiko Kurabayashi
- Department of Medicine and Biological Science, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
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HIRAI YUKOH, WEN MINGSHIEN, YEH SANJOU, WU DELONG. A Specific Sign for Differential Diagnosis of Atypical Atrioventricular Nodal Reentrant Tachycardia from Atrial Tachycardia. Pacing Clin Electrophysiol 2012; 35:245-8. [DOI: 10.1111/j.1540-8159.2011.03249.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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BHATTACHARYA SANJOY, SABA SAMIR. Pacing Maneuver in the Diagnosis of the Mechanism of Supraventricular Tachycardia. Pacing Clin Electrophysiol 2011; 34:e90-3. [DOI: 10.1111/j.1540-8159.2010.02812.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Metzl MD, Gross JN, Fisher JD, Krumerman AK. Wide complex tachycardia with cycle length alternans: What is the mechanism? Heart Rhythm 2011; 8:326-7. [DOI: 10.1016/j.hrthm.2010.04.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2010] [Indexed: 10/19/2022]
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LIM PHANGBOON, LINTON NICKW, SALUKHE TUSHARV, KOJODJOJO PIPIN, KOA-WING MICHAEL, STUBER THOMAS, DAVIES DWYN, KANAGARATNAM PRAPA, PETERS NICHOLASS, O'NEILL MARKD. His Delay: A Case of Ice on the Path? J Cardiovasc Electrophysiol 2008; 19:995-6. [DOI: 10.1111/j.1540-8167.2008.01237.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Sarkozy A, Richter S, Chierchia GB, De Asmundis C, Seferlis C, Brugada P, Kaufman L, Buyl R, Dorian P, Mangat I. A novel pacing manoeuvre to diagnose atrial tachycardia. Europace 2008; 10:459-66. [DOI: 10.1093/europace/eun032] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Irregular atypical atrioventricular nodal reentrant tachycardia: Incidence, electrophysiological characteristics, and effects of slow pathway ablation. Heart Rhythm 2007; 4:1507-22. [DOI: 10.1016/j.hrthm.2007.08.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2007] [Accepted: 08/10/2007] [Indexed: 11/18/2022]
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Ito T, Kaneko Y, Taniguchi Y, Nakajima T, Manita M, Suguta M, Kurabayashi M, Nagai R. Long RP tachycardia with RR alternation. Pacing Clin Electrophysiol 2000; 23:2128-30. [PMID: 11202259 DOI: 10.1111/j.1540-8159.2000.tb00788.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- T Ito
- Second Department of Internal Medicine, Gunma University School of Medicine, Maebashi, Gunma, Japan
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Knight BP, Ebinger M, Oral H, Kim MH, Sticherling C, Pelosi F, Michaud GF, Strickberger SA, Morady F. Diagnostic value of tachycardia features and pacing maneuvers during paroxysmal supraventricular tachycardia. J Am Coll Cardiol 2000; 36:574-82. [PMID: 10933374 DOI: 10.1016/s0735-1097(00)00770-1] [Citation(s) in RCA: 233] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES The purpose of this prospective study was to quantitate the diagnostic value of several tachycardia features and pacing maneuvers in patients with paroxysmal supraventricular tachycardia (PSVT) in the electrophysiology laboratory. BACKGROUND No study has prospectively compared the value of multiple diagnostic tools in a large group of patients with PSVT. METHODS One hundred ninety-six consecutive patients who had 200 inducible sustained PSVTs during an electrophysiology procedure were included. The diagnostic values of four baseline electrophysiologic parameters, nine tachycardia features and five diagnostic pacing maneuvers were quantified. RESULTS The only tachycardia characteristic that was diagnostic of atrioventricular (AV) nodal reentry was a septal ventriculoatrial (VA) time of <70 ms, and no pacing maneuver was diagnostic for AV nodal reentry. An increase in the VA interval with the development of a bundle branch block was the only tachycardia characteristic that was diagnostic for orthodromic tachycardia, but it occurred in only 7% of all tachycardias. An atrial-atrial-ventricular response upon cessation of ventricular overdrive pacing was diagnostic of atrial tachycardia, and this maneuver could be applied to 78% of all tachycardias. Burst ventricular pacing excluded atrial tachycardia when the tachycardia terminated without depolarization of the atrium, but the result could be obtained only in 27% of patients. CONCLUSIONS This prospective study quantitates the diagnostic value of multiple observations and pacing maneuvers that are commonly used during PSVT in the electrophysiology laboratory. The findings demonstrate that diagnostic techniques rarely provide a diagnosis when used individually. Therefore, careful observations and multiple pacing maneuvers are often required for an accurate diagnosis during PSVT. The results of this study provide a useful reference with which new diagnostic techniques can be compared.
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Affiliation(s)
- B P Knight
- Department of Internal Medicine, University of Michigan Health System, Ann Arbor 48109-0022, USA.
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Abstract
Prevention and attenuation of ischemia and reperfusion injury in patients with acute coronary syndrome are critically important for cardiologists. To save these patients from deleterious ischemic insults, there are three different strategies. The first strategy is to increase ischemic tolerance before the onset of myocardial ischemia; the second is to attenuate the ischemia and reperfusion injury when an irreversible process of myocardial cellular injury occurs; the third is to treat the ischemic chronic heart failure that is caused by acute myocardial infarction. Adenosine, which is known to be cardioprotective against ischemia and reperfusion injury, may merit being used for these three cardioprotection strategies. First of all, adenosine induces collateral circulation via induction of growth factors, and triggers ischemic preconditioning, both of which induce ischemic tolerance in advance. Secondly, endogenous adenosine may mediate the infarct size-limiting effect of ischemic preconditioning, and exogenous adenosine is known to attenuate ischemia and reperfusion injury. Thirdly, we also revealed that adenosine metabolism is changed in patients with chronic heart failure, and increases in adenosine levels may attenuate the severity of ischemic heart failure. Therefore, adenosine therapy may improve the pathophysiology of ischemic chronic heart failure. Taking these factors together, we hereby propose potential tools for cardioprotection attributable to adenosine in ischemic hearts, and we postulate the use of adenosine therapy before, during, and after the onset of acute myocardial infarction.
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Affiliation(s)
- M Kitakaze
- Department of Internal Medicine and Therapeutics, Osaka University School of Medicine, Suita, Japan
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