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Higuchi S, Li R, Gerstenfeld EP, Liem LB, Im SI, Kalantarian S, Ansari M, Abreau S, Barrios J, Scheinman MM, Tison GH. Identification of supraventricular tachycardia mechanisms with surface electrocardiograms using a convolutional neural network. Heart Rhythm O2 2023; 4:491-499. [PMID: 37645266 PMCID: PMC10461210 DOI: 10.1016/j.hroo.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023] Open
Abstract
Background It remains difficult to definitively distinguish supraventricular tachycardia (SVT) mechanisms using a 12-lead electrocardiogram (ECG) alone. Machine learning may identify visually imperceptible changes on 12-lead ECGs and may improve ability to determine SVT mechanisms. Objective We sought to develop a convolutional neural network (CNN) that identifies the SVT mechanism according to the gold standard of SVT ablation and to compare CNN performance against experienced electrophysiologists among patients with atrioventricular nodal re-entrant tachycardia (AVNRT), atrioventricular reciprocating tachycardia (AVRT), and atrial tachycardia (AT). Methods All patients with 12-lead surface ECG during sinus rhythm and SVT and had successful SVT ablation from 2013 to 2020 were included. A CNN was trained using data from 1505 surface ECGs that were split into 1287 training and 218 test ECG datasets. We compared the CNN performance against independent adjudication by 2 experienced cardiac electrophysiologists on the test dataset. Results Our dataset comprised 1505 ECGs (368 AVNRT, 304 AVRT, 95 AT, and 738 sinus rhythm) from 725 patients. The CNN areas under the receiver-operating characteristic curve for AVNRT, AVRT, and AT were 0.909, 0.867, and 0.817, respectively. When fixing the specificity of the CNN to the electrophysiologist adjudicators' specificity, the CNN identified all SVT classes with higher sensitivity: (1) AVNRT (91.7% vs 65.9%), (2) AVRT (78.4% vs 63.6%), and (3) AT (61.5% vs 50.0%). Conclusion A CNN can be trained to differentiate SVT mechanisms from surface 12-lead ECGs with high overall performance, achieving similar performance to experienced electrophysiologists at fixed specificities.
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Affiliation(s)
- Satoshi Higuchi
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California, San Francisco, San Francisco, California
| | - Roland Li
- Division of Cardiology, Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Edward P. Gerstenfeld
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California, San Francisco, San Francisco, California
| | - L. Bing Liem
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California, San Francisco, San Francisco, California
- Division of Cardiology, San Francisco VA Medical Center, San Francisco, California
| | - Sung Il Im
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California, San Francisco, San Francisco, California
| | - Shadi Kalantarian
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California, San Francisco, San Francisco, California
| | - Minhaj Ansari
- Division of Cardiology, Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Sean Abreau
- Division of Cardiology, Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Joshua Barrios
- Division of Cardiology, Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Melvin M. Scheinman
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California, San Francisco, San Francisco, California
| | - Geoffrey H. Tison
- Division of Cardiology, Department of Medicine, University of California, San Francisco, San Francisco, California
- Bakar Computational Health Sciences Institute, University of California, San Francisco, San Francisco, California
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Sasmita BR, Luo S, Huang B. Wide and Narrow QRS Complex Tachycardia With Cycle Length Alternans: What Is the Mechanism? Circulation 2021; 144:1824-1826. [PMID: 34843393 DOI: 10.1161/circulationaha.121.057578] [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: 11/16/2022]
Affiliation(s)
- Bryan Richard Sasmita
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Yuzhong District, Chongqing, China
| | - Suxin Luo
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Yuzhong District, Chongqing, China
| | - Bi Huang
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Yuzhong District, Chongqing, China
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Brugada J, Katritsis DG, Arbelo E, Arribas F, Bax JJ, Blomström-Lundqvist C, Calkins H, Corrado D, Deftereos SG, Diller GP, Gomez-Doblas JJ, Gorenek B, Grace A, Ho SY, Kaski JC, Kuck KH, Lambiase PD, Sacher F, Sarquella-Brugada G, Suwalski P, Zaza A. 2019 ESC Guidelines for the management of patients with supraventricular tachycardiaThe Task Force for the management of patients with supraventricular tachycardia of the European Society of Cardiology (ESC). Eur Heart J 2021; 41:655-720. [PMID: 31504425 DOI: 10.1093/eurheartj/ehz467] [Citation(s) in RCA: 508] [Impact Index Per Article: 169.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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Murphy L, Malouf KA, Nakamura RK. ECG of the Month. J Am Vet Med Assoc 2021; 257:707-709. [PMID: 32955397 DOI: 10.2460/javma.257.7.707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Suszko A, Nayyar S, Labos C, Nanthakumar K, Pinter A, Crystal E, Chauhan VS. Microvolt QRS Alternans Without Microvolt T-Wave Alternans in Human Cardiomyopathy: A Novel Risk Marker of Late Ventricular Arrhythmias. J Am Heart Assoc 2020; 9:e016461. [PMID: 32806990 PMCID: PMC7660784 DOI: 10.1161/jaha.119.016461] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background Action potential alternans can induce ventricular tachyarrhythmias and manifest on the surface ECG as T‐wave alternans (TWA) and QRS alternans (QRSA). We sought to evaluate microvolt QRSA in cardiomyopathy patients in relation to TWA and ventricular tachyarrhythmia outcomes. Methods and Results Prospectively enrolled cardiomyopathy patients (n=100) with prophylactic defibrillators had 12‐lead ECGs recorded during ventricular pacing from 100 to 120 beats/min. QRSA and TWA were quantified in moving 128‐beat segments using the spectral method. Segments were categorized as QRSA positive (QRSA+) and/or TWA positive (TWA+) based on ≥2 precordial leads having alternans magnitude >0 and signal:noise >3. Patients were similarly categorized based on having ≥3 consecutive segments with alternans. TWA+ and QRSA+ occurred together in 31% of patients and alone in 18% and 14% of patients, respectively. Although TWA magnitude (1.4±0.4 versus 4.7±1.0 µV, P<0.01) and proportion of TWA+ studies (16% versus 46%, P<0.01) increased with rate, QRSA did not change. QRS duration was longer in QRSA+ than QRSA‐negative patients (138±23 versus 113±26 ms, P<0.01). At 3.5 years follow‐up, appropriate defibrillator therapy or sustained ventricular tachyarrhythmia was greater in QRSA+ than QRSA‐negative patients (30% versus 8%, P=0.02) but similar in TWA+ and TWA‐negative patients. Among QRSA+ patients, the event rate was greater in those without TWA (62% versus 21%, P=0.02). Multivariable Cox analysis revealed QRSA+ (hazard ratio [HR], 4.6; 95% CI, 1.5–14; P=0.009) and QRS duration >120 ms (HR, 4.1; 95% CI, 1.3–12; P=0.014) to predict events. Conclusions Microvolt QRSA is novel phenomenon in cardiomyopathy patients that can exist without TWA and is associated with QRS prolongation. QRSA increases the risk of ventricular tachyarrhythmia 4‐fold, which merits further study as a risk stratifier.
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Affiliation(s)
- Adrian Suszko
- Peter Munk Cardiac Center University Health Network Toronto Ontario Canada
| | - Sachin Nayyar
- Peter Munk Cardiac Center University Health Network Toronto Ontario Canada
| | | | | | - Arnold Pinter
- Division of Cardiology St. Michael's Hospital Toronto Ontario Canada
| | - Eugene Crystal
- Division of Cardiology Sunnybrook Health Sciences Center Toronto Ontario Canada
| | - Vijay S Chauhan
- Peter Munk Cardiac Center University Health Network Toronto Ontario Canada
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Demirtaş AO, Icen YK, Kaypaklı O, Koca H, Ünal İ, Köseoğlu Z, Sahin DY, Koc M. A new criterion to differentiate atrioventricular nodal reentrant tachycardia from atrioventricular reciprocating tachycardia: Combined AVR criterion. J Electrocardiol 2018; 51:1045-1051. [PMID: 30497728 DOI: 10.1016/j.jelectrocard.2018.08.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 08/04/2018] [Accepted: 08/18/2018] [Indexed: 10/28/2022]
Abstract
AIM A combined aVR criterion is described as the presence of a pseudo r' wave in aVR during tachycardia in patients without r' wave in aVR in sinus rhythm and/or a ≥50% increase in r' wave amplitude compared to sinus rhythm in patients with r' wave in the basal aVR lead. We aimed to investigate the use of combined aVR criterion in differential diagnosis of atrioventricular nodal reentrant tachycardia (AVNRT) and atrioventricular reciprocating tachycardia (AVRT). METHODS In this prospective study, 480 patients with inducible narrow QRS supraventricular tachycardia (SVT) were included. Twelve-lead electrocardiogram (ECG) was conducted during tachycardia and sinus rhythm. The patients were divided into two groups according to the arrhythmia mechanism that determined via EPS, AVNRT, and AVRT. Criteria of narrow QRS complex tachycardia were compared between the two groups. RESULTS AVNRT was present in 370 (77%) patients and AVRT in 110 (23%) patients. Combined aVR criterion was found to be more frequent in patients with AVNRT (84.1% and 9.1%, p < 0.001). In logistic regression analysis, combined aVR criterion and classical ECG criterion were found to be the most important predictors of AVNRT (p < 0.001). The sensitivity, specificity, positive predictive value, and negative predictive value of the combined aVR criterion for AVNRT were 84.1%, 90.9%, 96.9%, and 62.9%, respectively. CONCLUSION In the differential diagnosis of patients with SVT, the combined aVR criterion identifies the presence of AVNRT with an independent and acceptable diagnostic value. In addition to classical ECG criteria for AVNRT, it is necessary to evaluate the combined aVR criterion in daily practice.
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Affiliation(s)
- Abdullah Orhan Demirtaş
- Department of Cardiology, University of Health Sciences - Adana Health Practice and Research Center, Adana, Turkey
| | - Yahya Kemal Icen
- Department of Cardiology, University of Health Sciences - Adana Health Practice and Research Center, Adana, Turkey
| | - Onur Kaypaklı
- Department of Cardiology, Mustafa Kemal University - Faculty of Medicine, Hatay, Turkey
| | - Hasan Koca
- Department of Cardiology, University of Health Sciences - Adana Health Practice and Research Center, Adana, Turkey
| | - İlker Ünal
- Department of Biostatistics, Cukurova University - Faculty of Medicine, Adana, Turkey
| | - Zikret Köseoğlu
- Emergency Medicine, Department of Emergency Medicine, University of Health Sciences - Adana Health Practice and Research Center, Adana, Turkey
| | - Durmus Yıldıray Sahin
- Department of Cardiology, University of Health Sciences - Adana Health Practice and Research Center, Adana, Turkey
| | - Mevlut Koc
- Department of Cardiology, University of Health Sciences - Adana Health Practice and Research Center, Adana, Turkey.
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Cedarbaum ER, Padmanabhan A, Goldschlager N. Electrical Alternans in Disguise-A Curious Case of Atrial Flutter. JAMA Intern Med 2018; 178:1704-1705. [PMID: 30383080 DOI: 10.1001/jamainternmed.2018.5291] [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: 11/14/2022]
Affiliation(s)
- Emily R Cedarbaum
- Department of Medicine, University of California, San Francisco, San Francisco
| | - Arun Padmanabhan
- Department of Medicine, University of California, San Francisco, San Francisco
| | - Nora Goldschlager
- Department of Medicine, University of California, San Francisco, San Francisco.,Division of Cardiology, Department of Medicine, Zuckerberg San Francisco General Hospital, San Francisco, California
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8
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Juliá J, Whitaker J, Wright M, O'Neill M. Alternating broad QRS complexes during tachycardia: What is the mechanism? J Cardiovasc Electrophysiol 2018; 29:638-640. [PMID: 29319203 DOI: 10.1111/jce.13422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 12/27/2017] [Accepted: 01/05/2018] [Indexed: 12/01/2022]
Affiliation(s)
- Justo Juliá
- Department of Cardiology, Cardiac Electrophysiology Unit, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - John Whitaker
- Division of Imaging Sciences and Biomedical Engineering, King's College London, St. Thomas' Hospital, London, UK
| | - Matthew Wright
- Department of Cardiology, Cardiac Electrophysiology Unit, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Mark O'Neill
- Department of Cardiology, Cardiac Electrophysiology Unit, Guy's and St. Thomas' NHS Foundation Trust, London, UK.,Division of Imaging Sciences and Biomedical Engineering, King's College London, St. Thomas' Hospital, London, UK
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Lloyd AJ, Littmann L. Demonstration of the rate-dependent rather than mechanism-dependent nature of electrical alternans in supraventricular tachycardia. J Electrocardiol 2016; 49:477-8. [PMID: 26925495 DOI: 10.1016/j.jelectrocard.2016.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Indexed: 11/18/2022]
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11
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Haghjoo M, Bahramali E, Sharifkazemi M, Shahrzad S, Peighambari M. Value of the aVR lead in differential diagnosis of atrioventricular nodal reentrant tachycardia. Europace 2012; 14:1624-8. [DOI: 10.1093/europace/eus109] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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González-Torrecilla E, Arenal A, Atienza F, Datino T, Atea LF, Calvo D, Pachón M, Miracle A, Fernández-Avilés F. EGC diagnosis of paroxysmal supraventricular tachycardias in patients without preexcitation. Ann Noninvasive Electrocardiol 2011; 16:85-95. [PMID: 21251139 DOI: 10.1111/j.1542-474x.2010.00399.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
This review is aimed at discussing the diagnostic value of the different electrocardiographic criteria so far described in the differential diagnosis of the major forms of paroxysmal supraventricular tachycardias (PSVTs). The predictive value of different combinations of these independent electrocardiographic (ECG) signs in distinguishing atrioventricular reentrant tachycardias (AVRTs) through a concealed accessory pathway (AP) versus atrioventricular nodal reentrant tachycardias (AVNRTs) are discussed in detail. In addition, the adjunctive diagnostic value of simple, bedside clinical variables and their combinations to the ECG interpretation in differentiating both tachycardia mechanisms is also reviewed.
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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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15
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Fox DJ, Tischenko A, Krahn AD, Skanes AC, Gula LJ, Yee RK, Klein GJ. Supraventricular tachycardia: diagnosis and management. Mayo Clin Proc 2008. [PMID: 19046562 DOI: 10.4065/83.12.1400] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Supraventricular tachycardia (SVT) includes all forms of tachycardia that either arise above the bifurcation of the bundle of His or that have mechanisms dependent on the bundle of His. We conducted a review of the techniques used to differentiate the mechanisms of SVT. We searched the PubMed and MEDLINE databases for English-language literature published from 1970 to 2008. Articles were selected for either their historical importance or up-to-date clinical data. This review focuses on techniques for scrutinizing electrocardiograms of patients, analyzing in particular the onset of tachycardia, the mode of tachycardia termination, and the effects of premature ventricular contractions, premature atrial contractions, and aberrancy during tachycardia. Both short-term and long-term management of SVT are examined, including the urgent treatment of patients in the emergency department. This review also describes management of patients who have ongoing symptomatic SVT, outlining such available treatment options as atrioventricular node-blocking drugs, antiarrhythmic drugs, and catheter ablation.
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Affiliation(s)
- David J Fox
- University of Western Ontario, Division of Cardiology, Arrhythmia Section, University Hospital, London, Ontario, Canada.
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Lee KW, Badhwar N, Scheinman MM. Supraventricular Tachycardia—Part II: History, Presentation, Mechanism, and Treatment. Curr Probl Cardiol 2008; 33:557-622. [DOI: 10.1016/j.cpcardiol.2008.06.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Santilli R, Perego M, Crosara S, Gardini F, Bellino C, Moretti P, Spadacini G. Utility of 12-Lead Electrocardiogram for Differentiating Paroxysmal Supraventricular Tachycardias in Dogs. J Vet Intern Med 2008; 22:915-23. [DOI: 10.1111/j.1939-1676.2008.0127.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Goldberger ZD, Rho RW, Page RL. Approach to the diagnosis and initial management of the stable adult patient with a wide complex tachycardia. Am J Cardiol 2008; 101:1456-66. [PMID: 18471458 DOI: 10.1016/j.amjcard.2008.01.024] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2007] [Revised: 01/16/2008] [Accepted: 01/16/2008] [Indexed: 11/29/2022]
Abstract
The initial electrocardiographic evaluation of every tachyarrhythmia should begin by addressing the question of whether the QRS complex is wide or narrow. The most important cause of wide complex tachycardia (WCT) is ventricular tachycardia. However, supraventricular tachycardia can also manifest with a wide QRS complex. The ability to differentiate between supraventricular tachycardia with a wide QRS due to aberrancy or preexcitation and ventricular tachycardia often presents a diagnostic challenge. The identification of whether WCT has a ventricular or supraventricular origin is critical because the treatment for each is different, and improper therapy may have potentially lethal consequences. In conclusion, although the diagnosis and treatment of sustained WCT often arise in emergency situations, this report focuses on a stepwise approach to the management of WCT in relatively stable adult patients, particularly the diagnosis and differentiation of ventricular tachycardia from supraventricular tachycardia with a wide QRS complex on standard 12-lead electrocardiography.
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Affiliation(s)
- Zachary D Goldberger
- Department of Internal Medicine, University of Washington Medical Center, VA Puget Sound Health Care System, Seattle, Washington, USA.
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Zhong YM, Guo JH, Hou AJ, Chen SJ, Wang Y, Zhang HC. A modified electrocardiographic algorithm for differentiating typical atrioventricular node re-entrant tachycardia from atrioventricular reciprocating tachycardia mediated by concealed accessory pathway. Int J Clin Pract 2006; 60:1371-7. [PMID: 16836647 DOI: 10.1111/j.1368-5031.2006.00839.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Non-invasive prediction of tachycardia mechanism is becoming clinically important in the era of catheter ablation for curing supraventricular tachycardia. Twelve-lead electrocardiograms (ECGs) during sinus rhythm and atrioventricular node re-entrant tachycardia (AVNRT) or atrioventricular reciprocating tachycardia (AVRT) with a narrow QRS complex were obtained from 154 consecutive adult patients who had received successful radiofrequency catheter ablation. The ECGs of initial 104 patients were analysed by three observers without knowledge of the electrophysiological diagnosis. The two arrhythmias were accurately diagnosed in 68% of cases. Three criteria were found to be discriminators of tachycardia mechanism by univariable analysis. Pseudo r/Q/S waves predicated AVNRT in 92% of cases (sensitivity 71%; specificity 95%). Retrograde P wave predicated AVRT in 86% of cases (sensitivity 75%; specificity 85%), RP interval > or =100 ms in 93% (sensitivity 71%; specificity 94%) and ST-segment elevation in lead aVR in 83% (sensitivity 71%; specficity 83%). According to the initial results, we proposed a modified stepwise ECG algorithm which used pseudo r/S/Q waves, RP interval and ST-segment elevation in lead aVR during tachycardia. Two observers assessed the modified algorithm in the remaining 50 patients. The algorithm was able to correctly diagnose the tachycardia mechanism in 84% and 87%, respectively. Using the modified algorithm can improve the accuracy and simplify the differential diagnosis between typical AVNRT and AVRT via concealed accessory pathway in adult patients.
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Affiliation(s)
- Y M Zhong
- Electrophysiology Laboratory, Department of Cardiology, Peking University People's Hospital, Beijing, China
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Erdinler I, Okmen E, Oguz E, Akyol A, Gurkan K, Ulufer T. Differentiation of narrow QRS complex tachycardia types using the 12-lead electrocardiogram. Ann Noninvasive Electrocardiol 2006; 7:120-6. [PMID: 12049683 PMCID: PMC7027638 DOI: 10.1111/j.1542-474x.2002.tb00152.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Previous studies have shown that only 80% of narrow QRS supraventricular tachycardia (SVT) types can be differentiated by standard 12-lead electrocardiographic (ECG) criteria. This study was designed to determine the value of some new ECG criteria in differentiating narrow QRS SVT. METHODS AND RESULTS 120 ECGs demonstrating paroxysmal narrow QRS complex tachycardia (QRS < or = 0.11 ms and rate > 120 beats/min) were analyzed. Forty atrioventricular reciprocating tachycardia (AVRT), 70 atrioventricular nodal reentrant tachycardia (AVNRT), and 10 atrial tachycardia defined with electrophysiologic study (EPS) consisted the study group. Eight surface ECG criteria were found to be significantly different between tachycardia types by univariate analysis. P waves separate from the QRS complex were observed more frequently in AVRT (70%) and atrial tachycardia (80%). Pseudo r' deflection in lead V(1), pseudo S wave in inferior leads, and cycle length alternans were more common in AVNRT (55, 20, and 6%, respectively). QRS alternans was also present during AVRT (28%). ST-segment depression (> or = 2 mm) or T-wave inversion, or both, were present more often in AVRT (60%) than in AVNRT (27%). During sinus rhythm, manifest preexcitation was observed more often in patients with AVRT (42%). When a P wave was present, RP/PR interval ratio > 1 was more common in atrial tachycardia (90%). By multivariate analysis, presence of a P wave separate from the QRS complex, pseudo r' deflection in lead V(1), QRS alternans, preexcitation during sinus rhythm, ST-segment depression > 2 mm or T-wave inversion, or both, were independent predictors of tachycardia type. CONCLUSIONS Several new ECG criteria may be useful in differentiation of SVT types. Prediction of mechanism prior to EPS may provide additional benefits concerning the fluoroscopic exposure time and cardiac catheterization procedure.
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Affiliation(s)
- Izzet Erdinler
- Department of Cardiology, Siyami Ersek Cardiovascular and Thoracic Surgery Center, Istanbul, Turkey
| | - Ertan Okmen
- Department of Cardiology, Siyami Ersek Cardiovascular and Thoracic Surgery Center, Istanbul, Turkey
| | - Enis Oguz
- Department of Cardiology, Siyami Ersek Cardiovascular and Thoracic Surgery Center, Istanbul, Turkey
| | - Ahmet Akyol
- Department of Cardiology, Siyami Ersek Cardiovascular and Thoracic Surgery Center, Istanbul, Turkey
| | - Kadir Gurkan
- Department of Cardiology, Siyami Ersek Cardiovascular and Thoracic Surgery Center, Istanbul, Turkey
| | - Tanju Ulufer
- Department of Cardiology, Siyami Ersek Cardiovascular and Thoracic Surgery Center, Istanbul, Turkey
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Abstract
Tachydysrhythmias arise from different mechanisms that can be characterized as being caused by re-entrant circuits, enhanced or abnormal automaticity, or triggered after-depolarizations. The approach to the tachydysrhythmia should begin with distinguishing sinus from non-sinus rhythms, then assessing QRS complex width and regularity. This article review tachydysrhythmias.
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Affiliation(s)
- Sarah A Stahmer
- Emergency Medicine, Cooper Hospital/University Medical Center, One Cooper Plaza, Room 114, Camden, NJ 08103, USA.
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Amasyali B, Kose S, Celik T. Atrioventricular nodal re-entrant tachycardia with QRS voltage and cycle length alternation and aberrant conduction due to two distinct antegrade slow pathways. Europace 2006; 8:134-7. [PMID: 16627425 DOI: 10.1093/europace/euj033] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
QRS voltage and cycle length alternation can be seen during supraventricular re-entrant tachycardias, especially in atrioventricular (AV) re-entrant tachycardia. We present a case of a 20-year-old man, in which AV nodal re-entrant tachycardia (AVNRT) shows alternation of QRS voltage and cycle length, as well as right bundle branch block aberration due to a re-entrant circuit using two distinct, beat-to-beat alternating slow AV nodal pathways antegradely and a single fast pathway retrogradely. Although more than one antegrade slow pathway exists, creation of a single lesion at the right posterior atrial septum using the conventional right-sided approach successfully eliminated AVNRT.
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Affiliation(s)
- Basri Amasyali
- Department of Cardiology, Gulhane Military Medical Academy, Etlik, Ankara, Turkey.
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Arya A, Kottkamp H, Piorkowski C, Schirdewahn P, Tanner H, Kobza R, Dorszewski A, Gerds-Li JH, Hindricks G. Differentiating atrioventricular nodal reentrant tachycardia from tachycardia via concealed accessory pathway. Am J Cardiol 2005; 95:875-8. [PMID: 15781021 DOI: 10.1016/j.amjcard.2004.12.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2004] [Revised: 12/14/2004] [Accepted: 12/14/2004] [Indexed: 10/25/2022]
Abstract
Studies analyzing the diagnostic value of 12-lead electrocardiographic criteria differentiating slow-fast atrioventricular nodal reentrant tachycardia (AVNRT) from atrioventricular reentrant tachycardia (AVRT) due to concealed accessory pathway have shown inconsistent results. In 97 patients (50 with AVNRT, 47 with AVRT) 12-lead electrocardiograms (ECGs) were recorded during sinus rhythm and tachycardia (QRS <120 ms). The ECGs were blinded for diagnosis and patient and analyzed independently by 2 electrophysiologists. The studied criteria differentiating AVNRT from AVRT included pseudo-r'/S, the presence of a retrograde P wave, RP interval, ST-segment depression >/=2 mm with the number and location of the affected leads, QRS amplitude, and cycle length alternans.
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Affiliation(s)
- Arash Arya
- Heart Center, Department of Electrophysiology, University of Leipzig, Leipzig, Germany
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25
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Jaeggi ET, Gilljam T, Bauersfeld U, Chiu C, Gow R. Electrocardiographic differentiation of typical atrioventricular node reentrant tachycardia from atrioventricular reciprocating tachycardia mediated by concealed accessory pathway in children. Am J Cardiol 2003; 91:1084-9. [PMID: 12714151 DOI: 10.1016/s0002-9149(03)00153-x] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The value of the electrocardiogram (ECG) in children with supraventricular tachycardia (SVT) is unclear. The noninvasive differentiation of typical atrioventricular node reentrant tachycardia (AVNRT) and atrioventricular reciprocating tachycardia (AVRT) mediated by concealed accessory pathway conduction is clinically important, as it helps in counseling and potentially facilitates ablation procedures. One hundred forty-eight ECGs showing narrow QRS complex SVT were obtained from children before successful radiofrequency catheter ablation. An initial 102 ECGs were analyzed by 3 blinded observers to assess the utility of various electrocardiographic findings. No electrocardiographic criteria were found to discriminate between SVT mechanisms on 1- to 3-channel Holter/event recorder tracings (n = 32); their interpretation mainly (55%) resulted in an incorrect SVT diagnosis. On 12-lead ECGs (n = 70), the 2 arrhythmias were accurately diagnosed in 76% of patients; 5 findings were found to be discriminators of tachycardia mechanism. Predictors of AVRT were visible P waves in 74% of cases (sensitivity 92%; specificity 64%), RP intervals of > or =100 ms in 91% (sensitivity 84%; specificity 91%), and ST-segment depression of > or =2 mm in 73% of cases (sensitivity 52%; specificity 82%). Pseudo r' waves in lead V(1) and pseudo S waves in the inferior leads during tachycardia predicted AVNRT in 100% of cases (sensitivity 55% and 20%, respectively; specificity 100% for both). Based on these results, we developed a new diagnostic 12-lead electrocardiographic algorithm for pseudo r'/S waves, RP duration, and ST-segment depression during tachycardia. Two observers tested the algorithm in 46 (21 AVNRT; 25 AVRT) additional cases; they correctly diagnosed the SVT mechanism in 91% and 87%, respectively. Thus, the stepwise use of diagnostically relevant 12-lead electrocardiographic parameters helps to more accurately differentiate mechanisms of reentrant SVT.
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Affiliation(s)
- Edgar T Jaeggi
- Pediatric Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada.
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26
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Herweg B, Weiner S, Ilercil A, Polosajian L, Ferrick KJ, Fisher JD. Cardiac memory, a surface electrocardiographic clue in the differential diagnosis of ongoing narrow complex tachycardia. Am J Cardiol 2002; 90:428-31. [PMID: 12161238 DOI: 10.1016/s0002-9149(02)02505-5] [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: 11/22/2022]
Affiliation(s)
- Bengt Herweg
- St. Luke's Roosevelt Hospital Center and Columbia University, New York, New York, USA
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27
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Abstract
Supraventricular tachycardias (SVT) comprise those tachycardias that originate above the bifurcation of the bundle of His. They can be classified broadly as AV node dependent and AV node independent. The mechanism and clinical manifestation of SVTs, which is essential to their correct diagnosis, is reviewed. The therapeutic management of SVTs, including acute and chronic drug therapy and catheter ablation, is discussed also.
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Affiliation(s)
- V S Chauhan
- Division of Cardiology, Department of Medicine, University of Western Ontario, London, Ontario, Canada
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28
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Abstract
Wide QRS complex tachycardia is a common clinical occurrence and presents a diagnostic challenge for the physician. History, physical examination, chest radiographs, and electrocardiographic analysis are important in making the correct diagnosis. Diagnosis of ventricular tachycardia is supported by history of prior myocardial infarction or congestive heart failure, physical examination showing cannon A-waves in the jugular venous pulsation or variable heart sounds, chest radiograph showing cardiomegaly or evidence of prior cardiac surgery, and characteristic ECG features: AV dissociation, fusion/capture beats, QRS concordance or typical morphologic features in leads V1 and V6. In this article, a clinical approach to wide QRS complex tachycardias is presented.
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Affiliation(s)
- A K Gupta
- Thoracic and Cardiovascular Institute, Michigan State University, Lansing, Michigan, USA
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29
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Wakimoto H, Izumida N, Asano Y, Hiraoka M, Kawara T, Hiejima K, Hirao TK, Suzuki F. Augmentation of QRS wave amplitudes in the precordial leads during narrow QRS tachycardia. J Cardiovasc Electrophysiol 2000; 11:52-60. [PMID: 10695462 DOI: 10.1111/j.1540-8167.2000.tb00736.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION QRS morphology during narrow QRS supraventricular tachycardia in patients without ventricular preexcitation generally is considered the same as that seen during sinus rhythm. This study presents a new ECG observation that the QRS amplitude increased significantly in leads V2 through V5 during tachycardia. METHODS AND RESULTS Using the same ECG machine and the same electrode patches applied to the same electrode positions, 12-lead ECGs during sinus rhythm and narrow QRS tachycardia were analyzed comparatively in 23 patients without ventricular preexcitation. Precordial QRS amplitudes were measured as the vertical distance from the peak of the R to the nadir of the S wave. The amplitudes also were measured during atrial rapid pacing and extrastimulation. Furthermore, ventricular excitation during sinus rhythm and tachycardia was studied using body surface mapping. Body surface distributions of QRS potentials and ventricular activation time (VAT) were displayed as maps. Gross area of QRS (AQRS, equivalent to the QRS amplitude) was compared during sinus rhythm versus tachycardia. During tachycardia, QRS amplitude significantly increased in leads V2 through V5, without any noticeable change in the transitional zone or QRS wave duration. Increase of QRS amplitude also was noted during atrial rapid pacing and extrastimulation. Gross AQRS values during tachycardia significantly increased in the left parasternal area, whereas QRS isopotential and VAT isochronal maps were similar during sinus rhythm and tachycardia, suggesting a minimal role of conduction delay in the increase of QRS amplitude. CONCLUSION QRS wave amplitude significantly increased in leads V2 through V5 during narrow QRS tachycardia compared with QRS waves in sinus rhythm. Increase of QRS amplitude seemed unlikely due to a conduction delay within the ventricular myocardium.
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Affiliation(s)
- H Wakimoto
- Department of Pediatrics, Medical Research Institute, Tokyo, Japan
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30
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DUGAL JS, GARG MK, SINGH AP. ECG DIAGNOSIS : SUPRAVENTRICULAR TACHYCARDIA. Med J Armed Forces India 1999; 55:373-374. [DOI: 10.1016/s0377-1237(17)30386-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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31
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Abstract
Wolff-Parkinson-White syndrome is the most common form of ventricular preexcitation. Understanding this syndrome is fundamental for anyone interested in learning about arrhythmias. This review addresses (1) the historic sequence of events that led to the understanding of this syndrome; (2) the pathologic, embryologic, and electrophysiologic properties of accessory pathways; (3) the epidemiology and genetics of this syndrome; (4) the clinical diagnosis of this syndrome, with special emphasis on the arrhythmias that patients with ventricular preexcitation are predisposed to; and (5) the therapy for patients with Wolff-Parkinson-White syndrome.
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Affiliation(s)
- S M Al-Khatib
- Department of Medicine, Duke University Medical Center, Durham, NC 27710, USA
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32
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Abstract
Wide QRS complex tachycardia is a frequently encountered arrhythmia in the emergency department and presents a diagnostic challenge to the emergency physician. The history, physical examination, chest radiograph, and electrocardiogram analysis are important in making the correct diagnosis. The diagnosis of ventricular tachycardia is supported by, 1) a history of prior myocardial infarction or congestive heart failure; 2) a physical examination showing cannon A-waves in the jugular venous pulsation or variable heart sounds; 3) a chest radiograph showing cardiomegaly or evidence of prior cardiac surgery; and 4) characteristic ECG features that include AV dissociation, fusion-capture beats, QRS concordance, or, typical morphologic features in leads V1 and V6. This article presents the diagnostic and therapeutic approaches to wide QRS tachycardias.
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Affiliation(s)
- C P Shah
- Department of Internal Medicine, Michigan State University, East Lansing, USA
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33
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Xie B, Thakur RK, Shah CP, Hoon VK. Clinical differentiation of narrow QRS complex tachycardias. Emerg Med Clin North Am 1998; 16:295-330. [PMID: 9621846 DOI: 10.1016/s0733-8627(05)70005-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Supraventricular tachycardias generally present with narrow QRS complexes and are quite commonly seen in the emergency department. Regular narrow QRS complex tachycardias occur in all age groups and may be associated with minimal symptoms, such as palpitations, or, present with hemodynamic compromise resulting in syncope. While history and physical examination are indispensable, they usually do not lead to a definitive diagnosis. The diagnosis is made by careful analysis of the 12-lead ECG. Therapy is based on hemodynamic assessment and understanding of the tachycardia mechanism.
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Affiliation(s)
- B Xie
- Department of Internal Medicine, Michigan State University, East Lansing, USA
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Murda'h MA, McKenna WJ, Camm AJ. Repolarization alternans: techniques, mechanisms, and cardiac vulnerability. Pacing Clin Electrophysiol 1997; 20:2641-57. [PMID: 9358511 DOI: 10.1111/j.1540-8159.1997.tb06113.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Sudden cardiac death continues to be the leading cause of mortality in developed countries. Electrical alternans of the ST segment and the T wave on the surface ECG as a noninvasive marker of patients at risk is a phenomenon that was initially observed early in this century and was seen then to be associated with cardiac rhythm disturbances. Substantial evidence indicates that T wave alternans (TWA) is related to myocardial ischemic as a harbinger of malignant ventricular arrhythmias because it reflects dispersion and heterogeneity of repolarization. Recent data have demonstrated a significant correlation between TWA and vulnerability to ventricular arrhythmias in individuals with or without organic heart disease, it also predicts the results of electrophysiological testing and arrhythmia-free survival in patients with a variety of cardiac diseases. This article reviews the historical background of TWA and discusses the early experimental and recent clinical evidence implying an integral link between TWA and ischemia-induced cardiac vulnerability.
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Affiliation(s)
- M A Murda'h
- Department of Cardiological Sciences, St. George's Hospital Medical School, London, United Kingdom
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35
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Brembilla-Perrot B, Lucron H, Schwalm F, Haouzi A. Mechanism of QRS electrical alternans. HEART (BRITISH CARDIAC SOCIETY) 1997; 77:180-2. [PMID: 9068405 PMCID: PMC484671 DOI: 10.1136/hrt.77.2.180] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
In patients with latent dual atrioventricular nodal pathways a 2:1 ventriculoatrial block often occurs during ventricular pacing and is generally associated with the concomitant appearance of QRS alternans. This type of QRS alternans is related to retrograde conduction, and a concealed retrograde conduction in the His Purkinje system could explain the QRS alternans. A case that confirms the hypothesis that electrical alternans is secondary to a 2:1 block in the activation of some part of the ventricles is reported.
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36
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Riva SI, Della Bella P, Fassini G, Carbucicchio C, Tondo C. Value of analysis of ST segment changes during tachycardia in determining type of narrow QRS complex tachycardia. J Am Coll Cardiol 1996; 27:1480-5. [PMID: 8626962 DOI: 10.1016/0735-1097(96)00013-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVES Repolarization changes during narrow QRS complex tachycardia were analyzed to differentiate the tachycardia mechanism and to guide the preliminary location of the accessory pathway. BACKGROUND Noninvasive determination of the mechanism of tachycardia is becoming increasingly important in view of the role of catheter ablation techniques for the cure of supraventricular tachycardia. METHODS We analyzed 159 12-lead electrocardiograms during narrow QRS complex tachycardia to evaluate 1) the tachycardia cycle; and 2) ST segment depression or T wave inversion, or both. Each patient underwent a complete electrophysiologic evaluation. RESULTS There were 13 atrial tachycardias, 57 atrioventricular (AV) node reentrant tachycardias and 89 AV reciprocating tachycardias. The mean RR cycle did not differ among types of tachycardia. ST segment depression >2 mm or T wave inversion, or both, was present more often in AV reciprocating tachycardia (57%) than in AV node tachycardia (25%). The magnitude of ST segment depression was greater in AV reciprocating tachycardia than in AV node tachycardia (mean +/- SD 1.3 +/- 1.6 vs. 0.7 +/- 0.8 mm, p < 0.005). In AV reciprocating tachycardia distinct patterns of repolarization changes and P wave configuration were associated with different sites of the accessory pathway. CONCLUSIONS The presence of ST segment depression >2 mm or T wave inversion, or both, during narrow QRS complex tachycardia suggests that AV reentry using an accessory pathway is the mechanism of the tachycardia. The phenomenon may be the consequence of a distinct pattern of retrograde atrial activation. Analysis of repolarization changes can guide preliminary localization of the accessory pathway even in the absence of ventricular preexcitation.
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Affiliation(s)
- S I Riva
- Instituto di Cardiologia, Universitá degli Studi, Milan, Italy
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37
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Fitzgerald DM, Hawthorne HR, Crossley GH, Simmons TW, Haisty WK. P wave morphology during atrial pacing along the atrioventricular ring. ECG localization of the site of origin of retrograde atrial activation. J Electrocardiol 1996; 29:1-10. [PMID: 8808519 DOI: 10.1016/s0022-0736(96)80105-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
P wave morphology during atrial pacing along the atrioventricular (AV) ring was evaluated to develop electrocardiographic (ECG) criteria for identifying the site of origin of the atrial activation wave during reentrant supraventricular tachycardia. Because P wave morphology changes as the pattern of atrial activation changes, the P wave should show characteristic morphologies during reentrant supraventricular tachycardia with use of either accessory AV pathways or the AV node for retrograde atrial activation. In 14 patients, 12-lead ECGs were recorded during bipolar atrial pacing at sites in the coronary sinus vein (along the mitral annulus) and along the atrial endocardium of the tricuspid annulus. P wave morphology was graded for each lead at each site. Sensitivity, specificity, and predictive value of ECG criteria for left versus right and anterior versus posterior atrial pacing sites were evaluated. Data were obtained from 14 sites along the AV ring, including 71 recordings at 6 sites in the coronary sinus vein and 94 recordings at 8 sites along the tricuspid annulus. These recordings were further divided into 54 anterior sites and 80 posterior sites, as well as 62 recordings along the right free wall and 32 recordings along the right atrial septum. The predictive value of a positive P wave in lead I indicating right atrial site of origin was 98.9%, and that for a negative or isoelectric P wave in lead I indicating a left atrial site of origin was 94.6%. Negative P wave in leads II, III, and aVF indicated a posterior site of origin, with a predictive value of 91.2%. The predictive value of a negative or isoelectric P wave in lead V1 indicating a right atrial free wall site was 87.5%. Thus, P wave morphology can be used to localize the site of origin of the atrial depolarization wave to a region along the AV ring.
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Affiliation(s)
- D M Fitzgerald
- Cardiology Section, Bowman Gray School of Medicine, Wake Forest University, Winston-Salem, North Carolina, 27157-1046, USA
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38
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Crosson JE, Dunnigan A. Propranolol induced electrical and mechanical alternans in orthodromic reciprocating tachycardia. Pacing Clin Electrophysiol 1993; 16:496-500. [PMID: 7681203 DOI: 10.1111/j.1540-8159.1993.tb01614.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
During an electrophysiological study in a patient with a concealed accessory connection, there was no evidence of electrical or mechanical alternans during tachycardia until propranolol was administered, but both forms of alternans developed with tachycardia of a slower rate following propranolol. Echocardiographic, arterial pressure, and electrocardiographic data obtained prior to and following propranolol administration are presented.
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Affiliation(s)
- J E Crosson
- Department of Pediatrics, University of Minnesota Hospital and Clinics, Minneapolis 55455
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39
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Vertongen P, Detollenaere M, Jordaens L. Changes of the RR interval and the QRS morphology in AV nodal tachycardia: further evidence for extranodal involvement. Pacing Clin Electrophysiol 1993; 16:261-6. [PMID: 7680453 DOI: 10.1111/j.1540-8159.1993.tb01574.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
A young patient with AV nodal tachycardia was referred for ablation. During electrophysiological testing, a stable succession of up to four different RR intervals with concomitantly changing QRS morphologies were recorded. This observation might reflect the conduction of the reentry circuit through different extranodal "pathways" in the low right atrium. Radiofrequency current was applied near the ostium of the coronary sinus; this abolished conduction through the slow pathway, as dual AV conduction was no longer present. She remains free of recurrences for a follow-up period of 8 months.
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Affiliation(s)
- P Vertongen
- Department of Cardiology, University Hospital, Ghent, Belgium
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40
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Kalbfleisch SJ, el-Atassi R, Calkins H, Langberg JJ, Morady F. Differentiation of paroxysmal narrow QRS complex tachycardias using the 12-lead electrocardiogram. J Am Coll Cardiol 1993; 21:85-9. [PMID: 8417081 DOI: 10.1016/0735-1097(93)90720-l] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVES The purpose of this study was to evaluate the utility of the 12-lead electrocardiogram (ECG) for differentiating paroxysmal narrow QRS complex tachycardias. BACKGROUND Previous studies evaluating the utility of the 12-lead ECG for differentiating paroxysmal supraventricular tachycardia types have shown conflicting results on the usefulness of some ECG criteria, and some criteria that are considered to be useful have never been formally evaluated. METHODS Two hundred forty-two ECGs demonstrating paroxysmal narrow QRS complex (< 0.11 ms) tachycardia (rate > or = 120 beats/min) were analyzed. All ECGs were analyzed by an observer who had no knowledge of the mechanism of the tachycardia. RESULTS There were 137 atrioventricular (AV) reciprocating tachycardias, 93 AV node reentrant tachycardias and 12 atrial tachycardias. Six criteria were found to be significantly different between tachycardia types by univariate analysis. A P wave separate from the QRS complex was observed more frequently in AV reciprocating tachycardia (68%) and atrial tachycardias (75%). A pseudo r' deflection in lead V1 and a pseudo S wave in the inferior leads were more common in AV node reentrant tachycardia (58% and 14%, respectively); QRS alternans was present more often during AV reciprocating tachycardia (27%). When a P wave was present, an RP/PR interval ratio > or = 1 was more common in atrial tachycardias (89%). During sinus rhythm, manifest pre-excitation was observed more often in patients with AV reciprocating tachycardia (45%). By multivariate analysis, the presence of a P wave separate from the QRS complex, pseudo r' deflection in lead V1, QRS alternans during tachycardia and the presence of pre-excitation during sinus rhythm were independent predictors of tachycardia type. These criteria correctly identified 86% of AV node reentrant tachycardias, 81% of AV reciprocating tachycardias and incorrectly assigned the tachycardia type in 19% of cases. CONCLUSIONS Several features on the ECG are useful for differentiating supraventricular tachycardia type. However, approximately 20% of tachycardias may be incorrectly classified on the basis of analysis of the ECG; therefore, the ECG should not serve as the sole means for determining tachycardia mechanism.
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Affiliation(s)
- S J Kalbfleisch
- Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor 48109-0022
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41
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Abstract
OBJECTIVES The purpose of this review is to assemble the widely dispersed information about cardiac alternans and to categorize the types and mechanisms of alternans, their clinical manifestations and possible therapeutic implications. BACKGROUND The phenomena of mechanical and electrical alternans have been of continuing interest to both physiologists and clinicians. Recent studies have enhanced this interest because of the reported association of alternans with experimental myocardial ischemia and cardiac arrhythmias. METHODS The review formulates concepts based on extensive review of published studies and personal observations. RESULTS Cardiac alternans has been subdivided into the following four categories: 1) mechanical, 2) electrical, 3) in association with myocardial ischemia, and 4) in association with cardiac motion. Mechanical alternans can be explained by hemodynamic or inotropic alterations, or both. Mechanical alternans in the ventricular muscle is accompanied by alternans of action potential shape. In the Purkinje fibers, action potential duration alternates without change in shape and is determined by the duration of the preceding diastolic interval. However, in ventricular muscle fiber, alternans can occur in the presence of constant diastolic intervals. T wave alternans reflects changes in action potential duration and is frequently associated with a long QT interval. Electrocardiographic manifestations of conduction alternans occur at many different sites within the conducting system and myocardium. During myocardial ischemia, additional mechanisms of repolarization alternans have been proposed. Alternans occurring in the presence of a large pericardial effusion is attributed to swinging motion of the heart maintaining two-beat periodicity. CONCLUSIONS Since its origin as "pulsus alternans" described by Traube in 1872, the definition of alternans has evolved into a term encompassing multiple physiologic and pathologic phenomena that, although united by the term cardiac alternans, diverge widely with respect to etiology, mechanism and clinical significance.
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Affiliation(s)
- B Surawicz
- Krannert Institute of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis 46202-4800
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42
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Abstract
The WPW syndrome is a curable disease. The evolution of nonpharmacological methods of accessory pathway ablation has had a significant impact on management strategies in patients with arrhythmias mediated by accessory pathways. Despite an incidence of preexcitation in the general population of 0.1% to 0.3%, curative therapy is underutilized. This review has highlighted the traditional and newer methods of diagnosing and localizing accessory pathways. The number of patients benefiting from definitive therapy will parallel increased physician awareness of these methods.
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Affiliation(s)
- M E Cain
- Cardiovascular Division, Washington University School of Medicine, St. Louis, Missouri
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43
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Affiliation(s)
- F Morady
- Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor 48109-0022
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46
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Pulignano G, Patruno N, Urbani P, Greco C, Critelli G. Electrophysiological significance of QRS alternans in narrow QRS tachycardia. Pacing Clin Electrophysiol 1990; 13:144-50. [PMID: 1689829 DOI: 10.1111/j.1540-8159.1990.tb05063.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
To investigate the electrophysiological significance of QRS alternans during narrow QRS tachycardia, transesophageal atrial pacing and recording was performed in 24 patients with a history of paroxysmal supraventricular tachycardia. Standard electrocardiograms showed ventricular preexcitation in 15 patients and normal QRS pattern in nine patients. The ventriculoatrial interval during tachycardia, as defined by means of transesophageal electrogram, allowed tentative diagnosis of the tachycardia mechanism. A 12-lead ECG was recorded either during spontaneous or induced tachycardia, as well as during transesophageal atrial pacing at increasing rates. Electrical alternans occurred spontaneously in eight patients (33%, group A): five with accessory pathway reentry (mean VA: 136 +/- 43 msec), and three with AV nodal reentry (mean VA: 48.3 +/- 12 msec). Tachycardia rate ranged between 170 and 230 beats/min (mean 200.7 +/- 16). In two patients, alternation of the QRS occurred only in the presence of a heart rate exceeding 180 and 190 beats/min, respectively. The amplitude of QRS remained stable during tachycardia in 16 patients (67%, group B): 14 had accessory pathway reentry (mean VA: 137.5 +/- 32 msec), and two had AV nodal reentry (mean VA: 45 +/- 7 msec). In this group, the tachycardia rate ranged from 150 to 210 beats/min (mean 175 +/- 12). Incremental transesophageal atrial pacing up to rates equal to that of tachycardia was performed in five patients from group A and in five patients from group B. Electrical alternans could not be induced in both groups with pacing at progressively increasing rates.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- G Pulignano
- Department of Cardiology, University of Rome, La Sapienza, Italy
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47
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Ellenbogen KA, Rogers RR, Szentpetery S. Electrophysiological observations during QRS alternans in a patient with incessant tachycardia. Pacing Clin Electrophysiol 1988; 11:413-8. [PMID: 2453036 DOI: 10.1111/j.1540-8159.1988.tb06000.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Electrophysiological observations during preoperative and intraoperative study of a 46-year-old patient with incessant ventricular tachycardia and QRS alternans demonstrated a potential mechanism for this electrocardiographic finding. During QRS alternans, conduction delay (or block) was recorded from the site of origin of the tachycardia, high on the anterior septum to the His bundle: After procainamide infusion, the tachycardias slowed and, concurrent with the disappearance of QRS alternans, conduction from the site of tachycardia origin to the His bundle could no longer be demonstrated.
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48
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Kuchar DL, Thorburn CW, Sammel NL, Garan H, Ruskin JN. Surface electrocardiographic manifestations of tachyarrhythmias: clues to diagnosis and mechanism. Pacing Clin Electrophysiol 1988; 11:61-82. [PMID: 2449674 DOI: 10.1111/j.1540-8159.1988.tb03930.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- D L Kuchar
- Department of Cardiovascular Medicine, St. Vincent's Hospital, Sydney, Australia
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Kremers MS, Wheelan KR, Solodyna M. Role of cycle length, cycle length alternans, and electrocardiographic lead in electrical alternans with rapid atrial pacing. Am J Cardiol 1987; 60:613-7. [PMID: 3630944 DOI: 10.1016/0002-9149(87)90315-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The role of cycle length and cycle length alternans in the induction of tachycardia-related QRS electrical alternans was investigated using an atrial pacing protocol in 16 patients. Pacing was performed at a cycle length less than 400 ms in 5 patients, greater than 400 ms in 5 and at both in 6 with 0, 6, 10, 20, 40 and 60 ms of atrial cycle length alternans. A 12-lead electrocardiogram and high right atrial, His bundle and right ventricular apical electrograms were simultaneously recorded after 30 to 60 seconds of pacing. Alternans was produced in 88% of patients. Alternans was 3 times more frequent at short (less than 400 ms) than long paced cycle lengths (greater than 400 ms) (66% vs 22%, p less than 0.0001). Alternans increased with increasing cycle length alternans and occurred with very little (less than or equal to 10 ms) atrioventricular nodal, His-Purkinje and ventricular cycle length alternans when paced cycle length was short. Alternans was more frequent in the precordial than the limb leads (45% vs 17%, p less than 0.001) and was most frequent in V3 and V2 (sensitivity 69% and 65%) and least frequent in leads I and aVL (sensitivity 4% and 10%). More leads per electrocardiogram showed alternans at short compared with long paced cycle lengths and the number of leads per electrocardiogram increased with increasing cycle length alternans. Occurrence of alternans was highly related to QRS amplitude by Spearman rank correlation (p less than 0.0005).(ABSTRACT TRUNCATED AT 250 WORDS)
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