ACCESSORY PATHWAYS AND SVT. Neil Grubb Royal Infirmary of Edinburgh
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1 ACCESSORY PATHWAYS AND SVT Neil Grubb Royal Infirmary of Edinburgh
2 Bypass tracts - properties accessory AV connections usually endocardial may exhibit unidirectional conduction conduction properties similar to His / Purkinje tissue not adenosine / calcium sensitive class Ic drugs most effective posteroseptal tracts may exhibit nodal properties beware epicardial pathways
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6 Avoiding Difficulties Preparation, preparation, preparation! have documentation of tachycardia onset and offset 12 leads if available pre-procedure echocardiogram identify atrial enlargement associated structural disease (e.g. Ebstein s) examine 12 lead in sinus rhythm pre-excitation pattern frontal axis and precordial transition helpful (rotation)
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10 Anterior Left Sided
11 Mid Septal Right Sided
12 Lateral Left Sided
13 Posteroseptal Right Sided
14 Posterior Left Sided
15 Free Wall Right Sided
16 Middle Cardiac Vein
17 Para-Hissian
18 Mapping: atrial pacing
19 Mapping: ventricular pacing
20 OAVRT: entrainment ΔVA (VA V pacing VA SVT ) <85ms PPI SVT CL <115ms
21 Polarity mapping
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23 Atrio-fascicular Pathways
24 Mahaim: atrial insertion
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26 THE DIFFICULT CASE Difficult Anatomy
27 Anatomical Challenges Inability to cannulate coronary sinus Eustachian valve / take off angle abnormal cardiac rotation (ECG, look at His / RV axis) big right atrium PRACTICAL POINTS use deflectable catheter; try from above do you need to see left sided activation? coronary arteriogram with venous phase
28 Anatomical Challenges Trans-septal puncture abnormal cardiac rotation (ECG, look at His / RV axis) thickened septum (previous procedures) PRACTICAL POINTS use CS and RV catheters as axis markers try different curve Do NOT puncture if it feels wrong! Consider TOE or ICE guidance and extra sharp needle
29 THE DIFFICULT CASE Septal conduction: AVNRT versus AVRT
30 Differential diagnosis of narrow QRS short RP tachycardia AVNRT AVRT with septal pathway accelerated junctional tachycardia atrial tachycardia with long PR interval
31 Criteria to support AVNRT critical prolongation of A-H interval initiates tachycardia concentric atrial activation, septal VA <65ms ventricular overdrive manoeuvre >115ms delta HA interval more positive than 10 Para-Hissian pacing generates nodal response decremental VA conduction termination by early PVC when His bundle nonrefractory
32 Para-Hissian pacing
33 Para-Hissian pacing
34 Ventricular Overdrive Manoeuvre Post-pacing interval = 508ms Tachycardia CL = 328ms PPI-TCL = 180ms (if PPI-TCL >115 suggests AVNRT)
35 Delta HA Interval based on the sequence of His bundle and atrial activation being fundamentally different in AVRT and AVNRT during tachycardia and during V pacing during tachycardia, in AVNRT His and A are activated simultaneously whereas in AVRT His and A are activated sequentially The opposite is true during V pacing
36 Delta HA Interval HOW TO PERFORM MANOEUVRE Measure HA inverval during tachycardia Measure HA interval with ventricular pacing Delta HA = HA paced HA SVT Delta HA more negative than -10 indicates AVRT Delta HA more positive than -10 indicates AVNRT AVNRT AVRT Mean SVT HA 104 ms 241 ms Mean paced HA 127 ms 151 ms Mean delta HA 21 ms -85 ms Miller JH et al. Am J Cardiol 1991;68:
37 Differential pacing
38 Differential pacing Martinez-Alday et al. Circulation 1994;89: HOW TO PERFORM MANOEUVRE pace at RV apex measure septal VA interval pace at RV base measure septal VA interval Ventriculoatrial index = VA (apex) VA (base) VA index > 10 ms always predicts accessory pathway
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41 Criteria to support AVRT inducible with ventricular pacing * advancement (reset) of tachycardia with Hissynchronous VPBs nondecremental VA conduction failure of VA conduction to block with adenosine
42 THE DIFFICULT CASE Posteroseptal Pathways
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54 CLOSING COMMENTS good preparation avoids many potential problems In WPW syndrome the surface ECG tells you where the pathway is most tachycardia mechanisms can be worked out using old-fashioned methods define the anatomy if you struggle with a posteroseptal pathway
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