Svt maneuvers hany abed

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Hany S. Abed B. Pharmacy, MBBS, PhD, IBHRE Certified EP and Cardiac Devices Specialist Clinical Cardiac Electrophysiology Fellow Loyola University Medical Center Techniques for Differentiating Supraventricular Tachycardias Concepts and Cases April 25 th 2014

Transcript of Svt maneuvers hany abed

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Hany S. Abed B . P h a r m a c y , M B B S , P h D , I B H R E C e r t i f i e d E P a n d C a r d i a c D e v i c e s S p e c i a l i s t

C l i n i c a l C a r d i a c E l e c t r o p h y s i o l o g y F e l l o w L o y o l a U n i v e r s i t y M e d i c a l C e n t e r

Techniques for Differentiating Supraventricular Tachycardias

Concepts and Cases

April 25th 2014

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Outline

Induction of tachycardia

Baseline tachycardia features

Diagnostic maneuvers during tachycardia

Diagnostic maneuvers in sinus rhythm after

tachycardia termination

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Induction of Tachycardia

Initiation by AES or atrial pacing

Requirement of AV conduction delay

Warm-up

VA interval

Initiation by VES or ventricular pacing

HA interval

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Initiation by AES or Atrial Pacing: Requirement of AV Conduction Delay

SVT initiation that is reproducibly dependent on a

critical AH interval:

Classic for typical AVNRT

Not always obvious with atypical AVNRT

May be present in AT but not a prerequisite

ORT often associated with AV delay but anterograde block in

the AAVC is key

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Initiation by AES or Atrial Pacing: Requirement of AV Conduction Delay

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Initiation by AES or Atrial Pacing

Warm-up

Characteristic but not exclusive of automatic AT

VA linking at induction

Compare VA interval of first tachycardia beat to the rest of SVT

If reproducibly identical, AT is very unlikely

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Initiation by VES or Ventricular Pacing

His Bundle-Atrial interval

Compare HA interval during during SVT with the HA interval occurring after a VES that results in an H-H interval similar to H-H during SVT

AVNRT

HASVT < HAVES

AVRT

HASVT > HAVES

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Baseline Tachycardia Features

Atrial activation sequence

Eccentric vs. Concentric

Is earliest “A” near AV rings?

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Baseline Tachycardia Features: PR/RP relationship

AT

PR interval usually longer than during SR

The faster the AT, the longer the PR interval

PR interval can be >, < or = to RP

Watch out for PR=RR resulting in P falling within QRS (AVNRT)

Typical AVNRT: VA typically -40 to 75 msec

Atypical AVNRT: long RP tach

PR and AH intervals often shorter than during SR

ORT: usually short RP but VA > 70 msec

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Baseline Tachycardia Features: AV block

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Baseline Tachycardia Features: AV block

Where is the block?

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Baseline Tachycardia Features: AV block

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Baseline Tachycardia Features: Oscillation in the TCL

SVT CL variability of ≥15 msec occurs in 73% of PSVT

Equally prevalent in AT, ORT, AVNRT

Changes in atrial CL precede and predict changes in ventricular CL

AT or atypical AVNRT

Changes in ventricular CL precede and predict changes in atrial CL

Typical AVNRT or ORT

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Baseline Tachycardia Features: Oscillation in the TCL

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Baseline Tachycardia Features: Oscillation in the TCL

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Baseline Tachycardia Features: Oscillation in the TCL and P-QRS

Variations in P-QRS relationship (AH, HA, AH/HA

ratio) especially at initiation or termination of SVT

Should not be misdiagnosed as AT

Often seen in atypical AVNRT

May be seen in typical AVNRT

Spontaneous changes in PR (AH) or RP (HA)

intervals with fixed A-A favor AT and exclude AVRT

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Baseline Tachycardia Features: Oscillation in the TCL and P-QRS

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Baseline Tachycardia Features: Effects of Bundle Branch Block

LBBB aberrancy during SVT is suggestive of ORT

BBB during SVT that does not prolong the VA (HA) interval excludes ORT using ipsilateral AAVC

May still be AVNRT, AT or ORT using contralateral AAVC

Prolongation of VA interval with BBB > 35 msec indicates ORT with ipsilateral free wall AAVC

Prolongation of VA interval < 25 msec suggests ORT utilizing a septal AAVC

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Baseline Tachycardia Features: Effects of Bundle Branch Block

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Outline

Induction of tachycardia

Baseline tachycardia features

Diagnostic maneuvers during tachycardia

Diagnostic maneuvers in sinus rhythm after

tachycardia termination

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Diagnostic Maneuvers During Tachycardia

AES during tachycardia Resetting

Termination

Atrial pacing during tachycardia Entrainment

Δ AH

Acceleration

Overdrive suppression

Termination

Differential site atrial pacing

VA interval in return cycle following cessation of pacing

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Atrial Extrastimulation During SVT: Resetting

AES can reset AT, AVNRT and ORT

Resetting with manifest atrial fusion

May be seen in ORT and macroreentrant AT

Not seen in AVNRT or focal AT

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Atrial Pacing During SVT: Entrainment

Overdrive atrial pacing can entrain macroreentrant

AT, AVNRT and ORT

Automatic or triggered AT cannot be entrained

Entrainment with manifest fusion in ORT or

macroreentrant AT (similar to AES concept)

VA linking

Compare postpacing VA interval to SVT VA interval

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Atrial Pacing During SVT: Entrainment

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Atrial Pacing During SVT: Overdrive Suppression

Return CL following the pacing train prolongs with

increasing duration and/or rate of pacing train

Suggests automatic AT

Entrained reentrant circuits have constant return

cycles regardless of the length of pacing drive

Warm up may be seen in automatic AT after

cessation of atrial pacing

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Atrial Pacing During SVT: Differential-Site Atrial Pacing

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Atrial Pacing During SVT: Differential-Site Atrial Pacing

Δ VA < 14 msec = ORT/AVNRT

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Atrial Pacing During SVT: Differential-Site Atrial Pacing

Δ VA > 14 msec = AT

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Atrial Pacing During SVT: Differential-Site Atrial Pacing

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Diagnostic Maneuvers During Tachycardia

VES during tachycardia

Resetting (His refractory VES, Preexcitation index)

Termination

Ventricular pacing during SVT

Atrial activation sequence

Entrainment

AV vs AAV response

Termination

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VES During SVT: His Refractory VES

VES delivered during SVT when the His potential is already manifest or within 35 to 55 msec before the time of the expected His potential

Advancing the next A +/- termination of SVT

Confirms presence of retrogradely conducting AAVC

Excludes AVNRT but not AT with bystander AAVC

Advancing the next A with activation sequence identical to SVT favors ORT over AT with bystander

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VES During SVT: His Refractory VES

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VES During SVT: His Refractory VES

Delay of the next A = ORT

Decremental conduction over AAVC

An innocent bystander AAVC cannot delay A during AT

Termination of SVT without an A = ORT

VA block in the AAVC

Note, even a well timed His refractory VES may not affect the next atrial activation if the stim is far from the site of the AAVC

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VES During SVT: His Refractory VES

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VES During SVT: His Refractory VES

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VES During SVT: Preexcitation Index

Preexcitation index: VES usually reset ORT

Distance between stim and ventricular insertion of AAVC

VES coupling interval (Preexcitation index)

PI > 75 msec suggests left free wall AAVC

PI < 45 msec suggests septal AAVC

The inability of single or double VESs to reset SVT despite advancement of all ventricular EGMs (including local V in EGM with earliest A) by > 30 msec excludes ORT

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VES During SVT: Preexcitation Index

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VES During SVT: Preexcitation Index

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AVNRT or ORT

Ventricular pacing during AVNRT and ORT reaches the atrium over the tachycardia retrograde limb

Atrial activation sequence during SVT = Retrograde atrial activation with V pacing during SVT

AT

Atrial activation during AT ≠ retrograde atrial activation with V pacing

Pitfall: AT originating close to AVJ

Beware bystander AAVC with retrograde conduction resulting in retrograde atrial activation during V pacing ≠ SVT even if due to AVNRT or ORT

Ventricular Pacing During SVT: Atrial Activation Sequence

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Ventricular Pacing During SVT: Entrainment

PPI – TCL and SA – VA

Original paper evaluated 30 patients with atypical AVNRT and 44 patients with ORT using a septal AAVC

Same criteria apply to typical AVNRT

For borderline values pace RV base instead of apex

PPI-TCL will be exaggerated in AVNRT (farther from circuit)

No significant change in ORT (still in the circuit for septal AAVCs)

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PPI - TCL and SA - VA

AVNRT

PPI - TCL = 150 msec SA – VA = 120 msec

*S-A measured from last pacing stimulus to HRA

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PPI - TCL and SA - VA

ORT

PPI - TCL= 80 msec SA – VA = 40 msec

*S-A measured from last pacing stimulus to HRA

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PPI - TCL and SA - VA

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Corrected PPI - TCL

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Traditional vs. Corrected PPI - TCL

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Manifest Ventricular Fusion During Entrainment

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Analysis of Transition Zone During Entrainment

Not dependent on tachycardia continuation after RVP

His bundle recording is unnecessary

AVNRT was identified with PPV and NPV of 100% using criteria of > 1 QRS of fixed morphology to accelerate TCL to PCL

A cut-off of ≤ 1 QRS of fixed morphology resulting in acceleration of TCL to PCL had a PPV and NPV of 100% for identifying ORT

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“Transition Zone” concepts: • AVRT circuit is large • AVNRT circuit is small • It is easier to get into the AVRT

circuit when pacing from the RV apex

• You will fuse and manifest into

the QRS quickly as you entrain the atrium in AVRT

• You will require more

progressive fusion of the QRS (less quickly) as you entrain the atrium in AVNRT

• Advantage is it is independent

of SVT termination after VOP • Need to look at all 12 ECG

leads

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Fixed

morphology

RVP beats

required to

accelerate

TCL to PCL

Analysis of Transition Zone During Entrainment

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Ventricular Pacing During SVT: A-V vs. A-A-V Response

A-V = AVNRT or ORT

Antegrade limb not refractory so able to conduct to V

A-A-V = AT

Antegrade limb (AVN) refractory since just used retrograde

Must confirm entrrainment before applying

Pseudo A-V and Pseudo A-A-V

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A-V Response

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A-A-V Response

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Pseudo A-V Response

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Pseudo A-V Response

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Pseudo A-A-V Response

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AAV or AV Response?

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Diagnostic Maneuvers in NSR After SVT Termination

Atrial pacing at TCL

ΔAH interval

AV block

Ventricular pacing at TCL

ΔHA interval

VA block

Atrial activation sequence

Differential RV pacing

Parahisian pacing

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Atrial Pacing at TCL: ΔAH Interval

AT/ORT

AH during SVT comparable to during A pacing at TCL due to similar activation

AVNRT

AH during SVT shorter than during A pacing at TCL due to different activation (parallel vs. series)

Δ AH (AHatrial pacing at TCL - AHSVT)

> 40 msec suggests AVNRT

< 20 msec suggests AT or ORT

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Atrial Pacing in Sinus Rhythm at TCL: ΔAH interval

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Atrial Pacing in Sinus Rhythm at TCL: ΔAH interval

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Atrial Pacing in Sinus Rhythm at TCL: ΔAH interval

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Atrial Pacing in Sinus Rhythm at TCL: AV block

AT/ORT

Atrial pacing at the TCL should result in 1:1 AV conduction

Should test shortly after SVT termination to maintain similar autonomic tone

The development of AV block with atrial pacing at TCL is consistent with AVNRT

Upper common pathway block

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AVNRT

HA activated in parallel during SVT and in series during ventricular pacing

HA during SVT shorter than during ventricular pacing at TCL

ORT

HA activated in series during SVT and in parallel during ventricular pacing

HA during SVT is longer than during ventricular pacing at TCL

Δ HA (HAV pacing at TCL – HASVT) more negative (<) than -10 msec = ORT

Δ HA > -10 msec = AVNRT

Ventricular Pacing in Sinus Rhythm at TCL: ΔHA interval

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Ventricular Pacing in Sinus Rhythm at TCL: ΔHA interval

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Ventricular Pacing in Sinus Rhythm at TCL: ΔHA interval

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Ventricular Pacing in Sinus Rhythm at TCL: ΔHA interval

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Ventricular Pacing in Sinus Rhythm at TCL: ΔHA interval

Greg Michaud et al

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Ventricular Pacing in Sinus Rhythm at TCL: VA Block

VA block during ventricular pacing makes ORT with a fast retrograde AAVC unlikely

More likely in setting of VA block

AT

AVNRT with lower common pathway block

PJRT

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Ventricular Pacing in Sinus Rhythm at TCL: Retrograde Atrial Activation Sequence

AVNRT

Atrial activation sequence usually similar during AVNRT and ventricular pacing in NSR

ORT Retrograde VA conduction during ventricular pacing may proceed

over the AVN, the AAVC, or both

Atrial activation sequence may be similar or different during ORT and ventricular pacing in NSR

AT

Atrial activation during AT ≠ retrograde atrial activation with V pacing

Pitfall: AT originating close to AVJ

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Maneuvers in NSR After SVT Termination: Differential RV Pacing

Compare VA interval and atrial activation sequence with pacing from RV base vs. RV apex

(-) Retrogradely conducting septal AAVC

Shorter VA interval when pacing from the apex

Same atrial activation sequence

(+) Retrogradely conducting septal AAVC

Shorter VA interval when pacing from base

Atrial activation sequence can be same or different depending on degree of contribution of AVN and AAVC

Pitfalls

Doesn’t exclude free wall AAVC or slowly conducting AAVC

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Maneuvers in NSR After SVT Termination: Differential RV Pacing

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Maneuvers in NSR After SVT Termination: Differential RV Pacing

2

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Maneuvers in NSR After SVT Termination: Parahisian Pacing

Ventricle and HB capture

Relatively narrow QRS

S-A interval = HA interval (direct His capture)

Only ventricular capture

Wide QRS, LBBB

S-A = S-H interval + HA interval

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Maneuvers in NSR After SVT Termination: Parahisian Pacing

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Maneuvers in NSR After SVT Termination: Parahisian Pacing

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Maneuvers in NSR After SVT Termination: Parahisian Pacing

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Case 1: Which arrhythmia mechanism can be excluded?

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Case 2: What arrhythmia mechanism can be confirmed?

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Cases 1 and 2: Coumel and Reverse Coumel

BCT LBBB and NCT, VA association, eccentric CS activation, no change in CL or VA time with

change from LBBB to NCT

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Case 3: What is the diagnosis and why?

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Case 3: Tachycardia termination

• NCT with A>V. Short VA time

• Cannot be AVRT

• AT or AVNRT (“atypical”)

• His refractory PVC terminates the

tachycardia without affecting the

atrium

• Can only be AVNRT with block below

the final common pathway

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Case 4: Describe the following?

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Case 5: Describe the following?

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Case 4 and 5: Para-His bundle pacing?

• No pathway: High output captures His and

myocardium via HPS

• No pathway: Low output captures septum

myocardium, travels to distal HPS to invade

retrograde

• Pathway present:

High output captures

His and pathway

(short-cut to atrium)

• Pathway present:

Low output captures

pathway and septum

myocardium (short-

cut to atrium)

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Case 4 and 5: Para-His bundle pacing elaborated

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Case 6: Which tachycardia mechanism is ruled out?

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Case 6: Tachycardia termination

Eccentric activation of the coronary sinus catheter suggests left lateral AP

However AVNRT utilising a leftward nodal extension cannot be excluded

• PVC terminated the

tachycardia without an early

(“pulling in”) atrial

electrogram

• Indicates the SVT is AVN

dependent – thus ruling out

FAT

• Note subtle delay in atrial

electrogram – suggests

decremental retrograde

conduction

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Case 6: PVC during SVT

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Case 7: Which tachycardia mechanism does the following

maneuver “rule-in”?

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Case 7: Which tachycardia mechanism does the following

maneuver “rule-in”?

• Note the PAC is delivered away from the septum. Being able to perturb the circuit far away

from the septum suggests a wide excitable gap.

• Compare that to AVNRT or Nodoventricular/Nodofascicular accessory pathway, which

have a narrow excitable gap

• If AVNRT with bystander accessory pathway: A His refractory PAC will advance next V,

BUT not “pull-in” the subsequent A.

• This is an antidromic AVRT using an AV

accessory pathway

• Delivering a PAC during His bundle

refractoriness advances the ventricle

• QRS morphology remains identical

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Case 8: What is the most likely tachycardia mechanism?

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Case 8: What is the most likely tachycardia mechanism?

• Pacing during sinus rhythm from the His bundle region does not conduct in the retrograde direction to the atrium.

• This makes AVRT very unlikely,

AVNRT unlikely. AT is most likely

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The End

H a n y S . A b e d B . P h a r m a c y , M B B S , P h D , I B H R E C e r t i f i e d E P a n d C a r d i a c D e v i c e s S p e c i a l i s t

C l i n i c a l C a r d i a c E l e c t r o p h y s i o l o g y F e l l o w

L o y o l a U n i v e r s i t y M e d i c a l C e n t e r

A p r i l 2 0 1 4