WPW syndrome and AVRT
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1 WPW syndrome and AVRT Myung-Yong Lee, MD, PhD Division of Cardiology Department of Internal Medicine School of Medicine Dankook University, Cheonan, Korea
2 Supraventricular tachycardia (SVT) Paroxysmal supraventricular tachycardia (PSVT) Atrial fibrillation (AF) Sinus tachycardia Physiologic sinus tachycardia Inappropriate sinus tachycardia Atrial tachycardia (AT) Focal AT Sinus node reentry tachycardia Multifocal atrial tachycardia (MAT) Atrial flutter Cavotricuspid isthmus dependent atrial flutter: typical Cavotricuspid isthmus dependent atrial flutter: reverse typical Atypical or non cavotricuspid isthmus dependent atrial flutter Junctional tachycardia Atrioventricular nodal reentrant tachycardia (AVNRT) Typical AVNRT Atypical AVNRT Accessory pathway Manifest accessory pathways Concealed accessory pathway Pre-excitation pattern Asymptomatic pre-excitation (isolated pre-excitation) Wolff-Parkinson-White syndrome Atrioventricular reentrant tachycardia (AVRT) Orthodromic AVRT Antidromic AVRT Permanent form of junctional reciprocating tachycardia An umbrella term used to describe tachycardias (atrial and/or ventricular rates in excess of 100 bpm at rest), the mechanism of which involves tissue from the His bundle or above. A clinical syndrome characterized by the presence of a regular and rapid tachycardia of abrupt onset and termination. PSVT represents a subset of SVT. Richard L. Page et al. Circulation. 2016;133:e506-e574
3 Supraventricular tachycardia (SVT) Paroxysmal supraventricular tachycardia (PSVT) An umbrella term used to describe tachycardias (atrial and/or ventricular rates in excess of 100 bpm at rest), the mechanism of which involves tissue from the His bundle or above. A clinical syndrome characterized by the presence of a regular and rapid tachycardia of abrupt onset and termination. PSVT represents a subset of SVT. Atrial fibrillation (AF) Sinus tachycardia Physiologic sinus tachycardia Inappropriate sinus tachycardia Atrial tachycardia (AT) Focal AT Sinus node reentry tachycardia Multifocal atrial tachycardia (MAT) Atrial flutter Cavotricuspid isthmus dependent atrial flutter: typical Cavotricuspid isthmus dependent atrial flutter: reverse typical Atypical or non cavotricuspid isthmus dependent atrial flutter Junctional tachycardia Atrioventricular nodal reentrant tachycardia (AVNRT) Typical AVNRT Atypical AVNRT Accessory pathway Manifest accessory pathways Concealed accessory pathway Pre-excitation pattern Asymptomatic pre-excitation (isolated pre-excitation) Wolff-Parkinson-White syndrome Atrioventricular reentrant tachycardia (AVRT) Orthodromic AVRT Antidromic AVRT Permanent form of junctional reciprocating tachycardia (PJRT) Richard L. Page et al. Circulation. 2016;133:e506-e574
4 Accessory Pathways Atrium and ventricle: insulated by cardiac skeleton Normally, AV node is the only electrical connection between A and V Gray's Anatomy. Published January 1, 2008 Copyright from The Royal College of Surgeons of England
5 Accessory Pathways and Reentry WPW syndrome Sinus rhythm Orthodromic Antidromic SAN SAN SAN AVN AVN AVN Concealed AP PJRT Mahaim SAN SAN SAN AVN AVN AVN
6 Accessory Pathways and Reentry WPW syndrome Sinus rhythm SAN AVN
7 Accessory Pathways and Reentry WPW syndrome Antidromic SAN AVN
8 Accessory Pathways and Reentry WPW syndrome Orthodromic SAN AVN
9 Differential Diagnosis of Narrow QRS tachycardia QRS duration Regularity P waves RP interval Richard L. Page et al. Circulation. 2016;133:e506-e574
10 Typical AVNRT Pseudo r in V1 Pseudo S in the inferior leads 2015 KHRS_ARC_3_DKUH_#1 10
11 AVRT with Retrograde P RP interval 100 msec
12 ECG algorithm for AP localization J Cardiovasc Electrophysiol 1998;9:2
13 Accessory Pathway: Left Free Wall
14 Accessory Pathway: Septal
15 Accessory Pathway: Right Free Wall
16 Differentiation of PSVT in EPS Baseline Observations and Tachycardia Features Prevalence (%) Positive Predictive Value (%) AVNRT ORT AT Pre-excitation present during sinus rhythm Extranodal response to para-hisian pacing VA block cycle length > 600 msec at baseline Septal VA interval > 70 msec Eccentric atrial activation Spontaneous AV block during tachycardia Spontaneous termination with AV block Development of LBBB Increase in VA interval > 20 msec with BBB
17 Eccentric Atrial Activation Distal CS Distal CS His His HRA Proximal CS RV HRA RV Proximal CS 2015 KHRS_ARC_3_DKUH_#3 17
18 Induction with AH Jump and Concentric Atrial Activation
19 His Synchronious Ventricular Extrastimulation (V reset) 406 msec 382 msec
20 His Synchronious Ventricular Extrastimulation (V reset) 20 msec
21 PPI-TCL: AVRT 510 msec 442 msec PPI-TCL = 68 (<115)
22 PPI-TCL: AVNRT 521 msec 337 msec PPI-TCL = 184 ( 115)
23 Coumel s law Positive Prediction Value: 100% in ORT Ipsilateral BBB produces prolonged TCL Narrrow QRS Ipsilateral BBB Contralateral BBB SAN SAN SAN AVN AVN AVN
24 Coumel s law 294 msec 251 msec 243 msec
25 294 msec 251 msec 243 msec SAN SAN SAN AVN AVN AVN +43 ms Ipsilateral BBB Narrrow QRS Contralateral BBB TCL: 294 ms TCL: 251 ms
26 Acute treatment of orthodromic AVRT Richard L. Page et al. Circulation. 2016;133:e506-e574
27 Acute treatment of orthodromic AVRT Richard L. Page et al. Circulation. 2016;133:e506-e574
28 Ongoing management of orthodromic AVRT Richard L. Page et al. Circulation. 2016;133:e506-e574
29 Success and Complication Rate for Ablation of AVRT Acute success rate: 93% Recurrent Rate: 8% Major Complications Overall 2.8% PPM 0.3% Death 0.1% Tamponade 0.4% Spector P, et al. Am J Cardiol. 2009;104: Calkins H, et al. Circulation. 1999;99:
30 RFCA
31 Hooray!!
32 Thank you for your attention
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