Use of Programmed Ventricular Extrastimulus During Supraventricular Tachycardia to Differentiate Atrioventricular Nodal Re-Entrant Tachycardia From Atrioventricular Re-Entrant Tachycardia

Hiroyuki Ito; Nitish Badhwar; Akash R Patel; Kurt S Hoffmayer; Joshua D Moss; Cara N Pellegrini; Vasanth Vedantham; Zian H Tseng; Ronn E Tanel; Henry H Hsia; Randall J Lee; Gregory M Marcus; Edward P Gerstenfeld; Melvin M Scheinman

doi:10.1016/j.jacep.2018.01.020

Use of Programmed Ventricular Extrastimulus During Supraventricular Tachycardia to Differentiate Atrioventricular Nodal Re-Entrant Tachycardia From Atrioventricular Re-Entrant Tachycardia

JACC Clin Electrophysiol. 2018 Jul;4(7):872-880. doi: 10.1016/j.jacep.2018.01.020. Epub 2018 Mar 28.

Affiliations

¹ Division of Cardiology, Department of Medicine, Showa University, Tokyo, Japan. Electronic address: hiroic2004@yahoo.co.jp.
² Section of Cardiac Electrophysiology, Division of Cardiology, University of California, San Francisco, San Francisco, California.
³ Division of Pediatric Cardiology, Department of Pediatrics, University of California, San Francisco, San Francisco, California.
⁴ Section of Electrophysiology, Division of Cardiology, University of California, San Diego, San Diego, California.
⁵ Section of Cardiac Electrophysiology, Division of Cardiology, University of California, San Francisco, San Francisco, California; San Francisco VA Medical Center, San Francisco, California.

PMID: 30025686
DOI: 10.1016/j.jacep.2018.01.020

Abstract

Objectives: This study hypothesized that early coupled ventricular extrastimuli (V₂) stimulation might yield a more robust differentiation between atrioventricular nodal re-entrant tachycardia (AVNRT) and atrioventricular re-entrant tachycardia (AVRT).

Background: Programmed V₂ during supraventricular tachycardia are useful to differentiate AVNRT from AVRT by subtracting the ventriculoatrial (VA) interval from the stimulus to atrial depolarization (stimulus atrial [SA]) interval, but all such maneuvers have limitations.

Methods: Patients with either AVNRT or AVRT were investigated. The entire tachycardia cycle length (TCL) was scanned with V₂ delivered from the right ventricular apex. The SA-VA difference was calculated with V₂ clearly resetting the tachycardia. The prematurity of V₂ was calculated by dividing the coupling interval (CI) by the TCL.

Results: A total of 210 patients (102 with AVNRT) were included. The SA-VA difference was >70 ms in all AVNRT patients and was <70 ms in all AVRT patients with right and septal accessory pathways (APs), except for those with decremental APs, in whom there was an overlap between AVNRT and AVRT with left APs. However, a SA-VA difference >110 ms with a CI/TCL of <65% distinguished AVNRT from AVRT using the left AP, with sensitivity and specificity of 87% and 100%, respectively. Ventricular overdrive pacing resulted in tachycardia termination or AV dissociation in 28% of patients compared with 15% of patients using the V₂ technique (p = 0.008).

Conclusions: A SA-VA of >70 ms using the V₂ technique differentiated AVNRT from AVRT using septal and right APs. Use of the V₂ technique with a short CI differentiated AVNRT from AVRT using left APs. The V₂ technique less frequently resulted in tachycardia termination compared with ventricular entrainment.

Keywords: coupling interval; premature ventricular extrastimulus; supraventricular tachycardia; ventricular entrainment; ventriculoatrial interval.

MeSH terms

Adolescent
Adult
Aged
Child
Electrophysiologic Techniques, Cardiac / methods*
Female
Heart Conduction System / physiopathology*
Heart Ventricles / physiopathology
Humans
Male
Middle Aged
Prospective Studies
Retrospective Studies
Tachycardia, Atrioventricular Nodal Reentry* / classification
Tachycardia, Atrioventricular Nodal Reentry* / diagnosis
Tachycardia, Supraventricular* / classification
Tachycardia, Supraventricular* / diagnosis
Young Adult