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Nagashima K, Michaud GF, Ho RT, Okumura Y. SVT quest: The adventure diagnosing narrow QRS tachycardia. J Arrhythm 2024; 40:767-785. [PMID: 39139886 PMCID: PMC11317754 DOI: 10.1002/joa3.13112] [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: 05/11/2024] [Revised: 06/19/2024] [Accepted: 06/30/2024] [Indexed: 08/15/2024] Open
Abstract
In the field of cardiac electrophysiology, there is a universal desire: the discovery of a flawless diagnostic maneuver for supraventricular tachycardias (SVTs). This is not merely a wish but a shared odyssey. To improve diagnostic accuracy and achieve sufficient sensitivity and specificity, numerous diagnostic maneuvers have been proposed. However, each has its limitations and prompts a search for new diagnostic techniques. This continuous cycle of discovery and refinement, which we titled "SVT Quest" is reviewed in chronological sequence. This adventure in diagnosing narrow QRS tachycardia unfolds in 3 steps: Step 1 involves differentiating atrial tachycardia from other SVTs based on the observations such as V-A-V or V-A-A-V response, ΔAA interval, VA linking, the last entrainment sequence, and response to the atrial extrastimulus. Step 2 focuses on differentiating orthodromic reciprocating tachycardia from atrioventricular nodal reentrant tachycardia based on the observations such as tachycardia reset upon the premature ventricular contraction during His refractoriness, uncorrected/corrected postpacing interval, differential ventricular entrainment, orthodromic His capture, transition zone analysis, and total pacing prematurity. Step 3 characterizes the concealed nodoventricular/nodofascicular pathway and His-ventricular pathway-related tachycardia based on observations such as V-V-A response, ΔatrioHis interval, and paradoxical reset phenomenon. There is no single diagnostic maneuver that fits all scenarios. Therefore, the ability to apply multiple maneuvers in a case allows the operator to accumulate evidence to make a likely diagnosis. Let's embark on this adventure!
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Affiliation(s)
- Koichi Nagashima
- Division of Cardiology, Department of MedicineNihon University School of MedicineTokyoJapan
| | - Gregory F. Michaud
- Division of Cardiovascular MedicineMassachusetts General HospitalBostonMassachusettsUSA
| | - Reginald T. Ho
- Division of Cardiology, Department of MedicineThomas Jefferson University HospitalPhiladelphiaPennsylvaniaUSA
| | - Yasuo Okumura
- Division of Cardiology, Department of MedicineNihon University School of MedicineTokyoJapan
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Nagashima K, Maruyama M, Kaneko Y, Sakai S, Sekihara T, Kawaji T, Iwakawa H, Egami Y, Ota C, Nagase S, Yagi T, Suzuki K, Fukaya H, Nakamura H, Mori H, Ueda A, Soejima K, Watanabe R, Wakamatsu Y, Hirata S, Hirata M, Okumura Y. Systematic observation-based diagnosis of atrioventricular nodal reentrant tachycardia with a bystander concealed nodoventricular pathway. J Arrhythm 2024; 40:131-142. [PMID: 38333409 PMCID: PMC10848616 DOI: 10.1002/joa3.12976] [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: 10/18/2023] [Revised: 11/20/2023] [Accepted: 12/05/2023] [Indexed: 02/10/2024] Open
Abstract
Background This study aimed to establish a systematic method for diagnosing atrioventricular nodal reentrant tachycardia (AVNRT) with a bystander concealed nodoventricular pathway (cNVP). Methods We analyzed 13 cases of AVNRT with a bystander cNVP, 11 connected to the slow pathway (cNVP-SP) and two to the fast pathway (cNVP-FP), along with two cases of cNVP-related orthodromic reciprocating tachycardia (ORT). Results The diagnostic process was summarized in three steps. Step 1 was identification of the presence of an accessory pathway by resetting the tachycardia with delay (n = 9) and termination without atrial capture (n = 4) immediately after delivery of a His-refractory premature ventricular contraction (PVC). Step 2 was exclusion of ORT by atrio-His block during the tachycardia (n = 4), disappearance of the reset phenomenon after the early PVC (n = 7), or dissociation of His from the tachycardia during ventricular overdrive pacing (n = 1). Moreover, tachycardia reset/termination without the atrial capture (n = 2/2) 1 cycle after the His-refractory PVC was specifically diagnostic. Exceptionally, the disappearance of the reset phenomenon was also observed in the two cNVP-ORTs. Step 3 was verification of the AVN as the cNVP insertion site, evidenced by an atrial reset/block preceding the His reset/block in fast-slow AVNRT with a cNVP-SP and slow-fast AVNRT with a cNVP-FP or His reset preceding the atrial reset in slow-fast AVNRT with a cNVP-SP. Conclusion AVNRT with a bystander cNVP can be diagnosed in the three steps with few exceptions. Notably, tachycardia reset/termination without atrial capture one cycle after delivery of a His-refractory PVC is specifically diagnostic.
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Affiliation(s)
- Koichi Nagashima
- Division of Cardiology, Department of MedicineNihon University School of MedicineTokyoJapan
| | - Mitsunori Maruyama
- Department of Cardiovascular MedicineNippon Medical School Musashikosugi HospitalKanagawaJapan
| | - Yoshiaki Kaneko
- Department of Cardiovascular MedicineGunma University Graduate School of MedicineGunmaJapan
| | - Satoshi Sakai
- Department of CardiologyNara Prefecture General Medical CenterNaraJapan
| | - Takayuki Sekihara
- Department of Cardiovascular MedicineOsaka University Graduate School of MedicineOsakaJapan
| | - Tetsuma Kawaji
- Department of CardiologyMitsubishi Kyoto HospitalKyotoJapan
| | - Hidehiro Iwakawa
- Department of Cardiovascular MedicineAkita University Graduate School of MedicineAkitaJapan
| | | | - Chisato Ota
- Department of Cardiovascular MedicineNational Cerebral and Cardiovascular CenterOsakaJapan
| | - Satoshi Nagase
- Department of Advanced Arrhythmia and Translational Medical ScienceNational Cerebral and Cardiovascular CenterOsakaJapan
| | - Tetsuo Yagi
- Department of CardiologySendai City HospitalMiyagiJapan
| | | | - Hidehira Fukaya
- Department of Cardiovascular MedicineKitasato University School of MedicineKanagawaJapan
| | - Hironori Nakamura
- Department of Cardiovascular MedicineKitasato University School of MedicineKanagawaJapan
| | - Hitoshi Mori
- Department of CardiologySaitama Medical University International Medical CenterSaitamaJapan
| | - Akiko Ueda
- Division of Advance Arrhythmia ManagementKyorin University HospitalTokyoJapan
| | - Kyoko Soejima
- Department of Cardiovascular MedicineKyorin University HospitalTokyoJapan
| | - Ryuta Watanabe
- Division of Cardiology, Department of MedicineNihon University School of MedicineTokyoJapan
| | - Yuji Wakamatsu
- Division of Cardiology, Department of MedicineNihon University School of MedicineTokyoJapan
| | - Shu Hirata
- Division of Cardiology, Department of MedicineNihon University School of MedicineTokyoJapan
| | - Moyuru Hirata
- Division of Cardiology, Department of MedicineNihon University School of MedicineTokyoJapan
| | - Yasuo Okumura
- Division of Cardiology, Department of MedicineNihon University School of MedicineTokyoJapan
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Nagashima K, Kaneko Y, Maruyama M, Nogami A, Kowase S, Mori H, Sumitomo N, Fukamizu S, Hojo R, Kitamura T, Soejima K, Ueda A, Otsuka T, Takami M, Tanimoto K, Asakawa T, Kumagai K, Tamura S, Hasegawa H, Ogura K, Kawamura M, Munetsugu Y, Shoda M, Higuchi S, Kanazawa H, Kusa S, Mizukami A, Miyazaki S, Wakamatsu Y, Okumura Y. Novel Diagnostic Observations of Nodoventricular/Nodofascicular Pathway-Related Orthodromic Reciprocating Tachycardia Differentiating From Atrioventricular Nodal Re-Entrant Tachycardia. JACC Clin Electrophysiol 2020; 6:1797-1807. [PMID: 33357576 DOI: 10.1016/j.jacep.2020.07.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 06/29/2020] [Accepted: 07/06/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVES This study sought to assess the performance of current diagnostic criteria and identify additional electrophysiological features differentiating orthodromic reciprocating tachycardia (ORT) with a concealed nodoventricular/nodofascicular (NV/NF) pathway from atrioventricular nodal re-entrant tachycardia (AVNRT). BACKGROUND Diagnosing sustained supraventricular tachycardia (SVT) despite the occurrence of ventriculoatrial block (VAB) is challenging. METHODS We analyzed electrograms of 25 sustained SVTs (9 NV/NF-ORTs [n = 7/2] and 16 AVNRTs) with VAB and 91 AVNRTs without VAB (for reference). RESULTS More than 1 SVT, each with a different ventriculoatrial interval, was commonly induced in AVNRT cases (75%) but not in NV/NF-ORT cases (0%; p = 0.0005). Wenckebach VAB was common in NV/NF-ORTs (78%), but VAB patterns varied in AVNRTs. The His-His interval transiently prolonged in the following beat after the VAB in most AVNRTs but rarely did in NV/NF-ORTs (79% vs. 22%; p = 0.01). NV/NF-ORT was diagnosed by His-refractory premature ventricular contractions (n = 5) and the findings during right ventricular overdrive pacing showing an uncorrected/corrected post-pacing interval (PPI)-tachycardia cycle length (TCL) ≤115/110 ms (n = 5/5), orthodromic His capture (n = 6), and V-V-A (ventricle-ventricle-atrial response) response (n = 3). A single form of induced SVT (positive predictive value [PPV]: 69%; negative predictive value [NPV]: 100%), Wenckebach VAB (PPV: 70%; NPV: 87%), stable His-His interval despite VAB (PPV: 70%; NPV: 85%), orthodromic His capture (PPV: 100%; NPV: 97%), and V-V-A response (PPV: 100%; NPV: 95%) characterized NV/NF-ORT, and a PPI-TCL of ≤125 ms (PPV: 100%; NPV: 100%) characterized NV-ORT. CONCLUSIONS Induction of a single SVT form, Wenckebach VAB, stable His-His interval despite VAB, orthodromic His capture, and V-V-A response appeared to discriminate NV/NF-ORT from AVNRT, with a PPI-TCL of ≤125 ms discriminating NV-ORT from NF-ORT and AVNRT.
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Affiliation(s)
- Koichi Nagashima
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Ibaraki, Tokyo, Japan.
| | - Yoshiaki Kaneko
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Mitsunori Maruyama
- Department of Cardiovascular Medicine, Nippon Medical School Musashikosugi Hospital, Tokyo, Japan
| | - Akihiko Nogami
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan; Department of Heart Rhythm Management, Yokohama Rosai Hospital, Yokohama, Kanagawa, Japan
| | - Shinya Kowase
- Department of Heart Rhythm Management, Yokohama Rosai Hospital, Yokohama, Kanagawa, Japan
| | - Hitoshi Mori
- Department of Pediatric Cardiology, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Naokata Sumitomo
- Department of Pediatric Cardiology, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Seiji Fukamizu
- Department of Cardiology, Tokyo Metropolitan Hiroo Hospital, Shibuya, Tokyo, Japan
| | - Rintaro Hojo
- Department of Cardiology, Tokyo Metropolitan Hiroo Hospital, Shibuya, Tokyo, Japan
| | - Takeshi Kitamura
- Department of Cardiology, Tokyo Metropolitan Hiroo Hospital, Shibuya, Tokyo, Japan
| | - Kyoko Soejima
- Department of Cardiovascular Medicine, Kyorin University Hospital, Mitaka, Tokyo, Japan
| | - Akiko Ueda
- Division of Advance Arrhythmia Management, Kyorin University Hospital, Mitaka, Tokyo, Japan
| | - Takayuki Otsuka
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Kobe, Japan
| | - Mitsuru Takami
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kojiro Tanimoto
- Department of Cardiology, Tokyo Medical Center, Tokyo, Japan
| | - Tetsuya Asakawa
- Department of Cardiology, Yamanashi Kosei Hospital, Yamanashi, Japan
| | - Kenta Kumagai
- Department of Cardiology, Odawara Cardiovascular Hospital, Odawara, Japan
| | - Shuntaro Tamura
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Hiroshi Hasegawa
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Kazuyoshi Ogura
- Division of Cardiovascular Medicine, Endocrinology and Metabolism, Department of Molecular Medicine and Therapeutics, Faculty of Medicine, Tottori University, Tottori, Japan
| | - Mitsuharu Kawamura
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Yumi Munetsugu
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Morio Shoda
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Satoshi Higuchi
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Hisanori Kanazawa
- Department of Cardiac Arrhythmias, Kumamoto University Hospital, Kumamoto, Japan
| | - Shigeki Kusa
- Division of Cardiology, Tsuchiura Kyodo Hospital, Tsuchiura, Japan
| | - Akira Mizukami
- Department of Cardiology, Kameda Medical Center, Kamagawa, Japan
| | - Shinsuke Miyazaki
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Yuji Wakamatsu
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Ibaraki, Tokyo, Japan
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Ibaraki, Tokyo, Japan
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