Supraventricular Tachycardias

AV Nodal Reentrant Tachycardia (AVNRT)

AVNRT
AVNRT Features •Pts usually young to middle aged adults •More common in females •Concentric (septal) retrograde atrial activation low to high •Pseudo R wave in V1 •Dual AV Nodal physiology common (fast and slow pathways) •Tachycardia is AV nodal dependent and is usually 1:1 AV conduction •Shortest VA during tachycardia is < 60 ms

Baseline ECG .

AVNRT 12 Lead: Pseudo R Wave .

AVNRT Sinus Rhythm .

AVNRT .

AV Nodal Jump With an Echo S1(A1) S1(A1) S2(A2) “echo” A H V A H V A H V A H V A 230 ms increase in AH to 450 ms “jump” (FPWERP and “jump” to SPW) .

AVNRT Induction “JUMP”(FPERP) Long AH Interval Up Fast Down Slow PW “ECHO” UF DS DS UF Sustained AVNRT .

Sustained AVNRT .

AVNRT Terminates with Adenosine .

Atrial Pacing Protocol Exercise: What is happening here? Which catheter is being paced? Is it capturing? How many “extras” are given? Is an arrhythmia induced? What happens to the AH interval? .

Atrioventricular Reciprocating Tachycardia (AVRT)Concealed Bypass Tracts and WPW .

.Accessory AV Pathways • “APs” represent an extra connection outside the AV Node • “Concealed” pathways have only retrograde conduction and do not have pre-excitation (NO delta wave in SR) • “Manifest” show antegrade conduction (delta wave in SR) • These patients represent 30% of all SVT’s.

cannot continue in the presence of AV nodal or VA block •Atrial preexcitation when his refractory proves AP •VA during tachycardia is > 60 ms •APs do not typically exhibit decremental conduction .AVRT AVRT Features •Hx of tachycardia typically beginning in childhood to young adult •More common in males •Concentric (septal) or eccentric retrograde atrial activation low to high •Tachycardia dependent on the AV node and the ventricles.

AVRT .

Nature of AVRT • May be orthodromic: down the AV node and up the accessory pathway resulting in narrow complex (90%) • May be antedromic: down the AP and up the AV node resulting in wide complex (10%) .

AVRT: Manifest AP .

AVRT: Manifest AP ERP .

AVRT: Orthodromic Down AV Node Up AP * Down AV Down AV Node Up AP Node * * Up AP .

Anatomic Locations Accessory Pathways Septal Free Wall Lateral .

AVRT: Orthodromic via L sided AP .

AVRT: AF With Pre-excitation .

AVRT: Ablation of Manifest AP .

AVRT: Manifest AP Delta Algorithm * * * * * * .

Algorithm for AP Identification * * II. I + and AVF + AVF - * * * * * * . III.

III. AVF) Negative in lead II Negative in the lateral leads (I and AVL) Making a – to + transition V1 to V2 Not meeting the above criteria The analysis of the delta wave polarity should occur during the first 25 ms of the manifest QRS complex. II. AVF) Negative in the inferior leads (II.Algorithm for AP Identification General Concepts for Manifest Pathways If Delta Wave Is Then Pathway is L sided Pathway is R sided Pathway is anterior Pathway is posterior In a vein (CS) or epicardial Pathway is left lateral Pathway is septal Multiple pathways may be present * * * * * * * * Positive in V1 Negative in V1 Positive in the inferior leads (II. .

AVRT What is happening here? What is the rhythm? Where is the shortest VA time? Where is the AP? .

where is this AP located? .AVRT Using the delta wave algorithm.

Diagnosing Septal Pathways Para-Hisian Pacing: Why and How .

• “Is that over the node or pathway?” .Why • Used to distinguish mid or anteroseptal accessory pathway from AV node when retrograde conduction is concentric.

• Stimuli delivered to the RV septum. distal to the His recording and proximal to the right bundle recording. • Pacing with high output to capture the His bundle directly (narrower QRS). then decrease output to no longer capture the His bundle (wider QRS).particularly the HIS bundle. but depolarize the ventricle from the high septum (capture only of local ventricular myocardium) .How • Pacing output rather than mere electrode location is used to capture different structures….

High Output His Capture (No AP) • Capture of the HIS bundle directly will spread the impulse to the AV node retrograde and to the ventricles over the HPS=narrower QRS Pace .

but ventricle is depolarized from the high septum yielding a left bundle branch block QRS morphology (wider QRS).Lower output: No His Capture (No AP) • His not captured as output reduced. Impulse travels to apex then retrograde to His-purkinje system to the atrium so the stim to atrial depolarization time is increased (no AP present) Pace .

Anteroseptal Accessory Pathway • In the presence of an AP. the retrograde activation is rapid regardless of the activation of the HPS system or ventricular septum (occurs with narrower or wider QRS) Pace .

45 ms – in S-H= 45 ms – in S-A w/o change in atrial activation . S-H shortens to 15 ms. without a change in the atrial activation sequence. The constant H-A interval (35 ms) and atrial activation sequence indicate that retrograde conduction was dependent on activation of the His bundle and not on the local ventricular myocardium and thus no AP • • Wider QRS: HB/RB not activated. H-A constant. HB-RB capture was achieved in the right complex reflected by narrowing of the QRS complex and shortening of the S-H interval to 15 ms.No AP (1) • Para-Hisian pacing demonstrating retrograde conduction over the fast AV nodal pathway (AVN/AVN pattern) in a patient with AVNRT.Late His Activation S-H=60 ms Narrower QRS: HB/RB activated. The 45-ms shortening in S-H interval was matched by a 45 ms shortening in the S-A interval from 90 to 45 ms.Para-Hisian pacing . reflected by the wide QRS complex and relatively late His bundle activation (S-H=60 ms). The pacing stimulus (S) in the left complex did not produce HB-RB capture.

45 ms – in S-H= 45 ms – in S-A w/o change in atrial activation .No AP (1) Wider QRS Narrower QRS Wider QRS: HB/RB not activated. H-A constant.Para-Hisian pacing . S-H shortens to 15 ms.Late His Activation S-H=60 ms Narrower QRS: HB/RB activated.

This was also associated with a 60-ms increase in the S-A interval from 120 to 180 ms. The pacing stimulus (S) in the left complex resulted in ventricular capture and HB-RB capture.Para-Hisian Pacing – No AP (2) Narrower QRS • Para-Hisian pacing demonstrating retrograde conduction over the slow AV nodal pathway (AVN/AVN pattern). S-A=120 ms Wider QRS • • Wider QRS: HB/RB not activated. resulting in widening of the QRS complex and a 60-ms increase in the S-H interval from 10 to 70 ms. not local V myocardium and no AP. S-H + by 60 ms (10 to 70 ms). S-H short=10 lateral accessory AV pathway. Earlier atrial activation in the proximal coronary sinus electrogram (CSp) than in the His bundle electrogram (HBp) suggests retrograde conduction over the slow AV nodal pathway. ms. Narrower QRS: HB/RB This tracing was recorded after ablation of a left activated. HB-RB capture was lost in the right complex. Constant H-A (110) and A activation =His dependent activation. without a change in the retrograde atrial activation sequence. The constant H-A interval (110 ms) and atrial activation sequence indicate that retrograde conduction was dependent on His bundle activation and not on local ventricular activation. indicating retrograde conduction exclusively over the AV node. S-A + by 60 ms (120 to 180 ms).Late His Activation. retro SPW (CS early) . producing a relatively narrow QRS complex and early activation of the His bundle (H).

S-H + by 60 ms (10 to 70 ms). Constant H-A (110) and A activation =His dependent activation. SA + by 60 ms (120 to 180 ms). S-A=120 ms Wider QRS: HB/RB not activated. not local V myocardium and no AP.Late His Activation. S-H short=10 ms. retro SPW (CS early) .Para-Hisian Pacing – No AP (2) Narrower QRS Wider QRS HA 110 HA 110 Narrower QRS: HB/RB activated.

Narrower QRS Wider QRS • • Narrower QRS: HB/RB Wider QRS: Loss of HB/RB. not retro H activation. S-A remains constant at 95 ms (if S-A dependent on H. S-A would also + by 55 ms— not the case here. S-H + by 55 ms to capture. The S-A interval remained fixed at 95 ms and the atrial activation sequence remained identical. A activation unchanged.AP Present (1) • Para-Hisian pacing demonstrating retrograde conduction only over an anteroseptal accessory AV pathway (AP/AP pattern). A activation dependent on V activation. thus AP present . indicating that retrograde conduction was dependent on the timing of ventricular activation and not on the timing of retrograde Hisbundle activation. Loss of HB-RB capture in the right complex resulted in a 55ms increase in S-H interval to 70 ms. HB-RB capture in the left complex resulted in an S-H interval of 15 ms. S-H=15 ms 70 ms.

S-A would also + by 55 ms—not the case here. thus AP present . A activation dependent on V activation. not retro H activation. S-H + by 55 ms to 70 ms. S-A remains constant at 95 ms (if S-A dependent on H. S-H=15 ms Wider QRS: Loss of HB/RB.AP Present (1) Narrower QRS Wider QRS HA 65 HA 25 Narrower QRS: HB/RB capture. A activation unchanged.

AP Present (2) Narrower QRS Wider QRS • The SA intervals and retrograde atrial activation sequence are unchanged. indicating retrograde conduction over a single accessory pathway. .

indicating retrograde conduction over a single accessory pathway.AP Present (2) Narrower QRS Wider QRS The SA intervals and retrograde atrial activation sequence are unchanged. .

Diagnosing Septal Pathways Para-Hisian Pacing: Summary: Wider QRS/Long S-H= Local Ventricular Capture Only Narrower QRS/Short S-H= His/RB Capture Shortening of S-H interval reflects His/RB capture S-A changes which follow S-H changes= Retro AV Node conduction S-A intervals which are short regardless of a “narrower” or “wider” QRS and which do not follow changes in the S-H interval are indicative of an AP .

Effects of Bundle Branch Block During Orthodromic Tachycardia .

In orthodromic AVRT with a LBBB and a left sided (here left lateral) AP. This occurs only when the block is on the same side as the AP-otherwise known as ipsilateral BBB. the circuit can only return to the AP via the right bundle and conduction via the left ventricular septum—therefore the VA time and the cycle length of the tachycardia is increased. Normal Orthodromic LBBB L Lat AP=Fixed TCL and VA Time w/ Narrow QRS L Lat AP= + TCL and VA Time w/ LBBB © Netter Images .

In orthodromic AVRT and a RBBB. while a contralateral (opposite side) BBB does not. Only a right sided pathway would be affected by a RBBB. nor the tachycardia cycle length is affected in the case of a left sided (here left lateral) AP. L Lat AP= No change in TCL and VA Time w/ RBBB © Netter Images . neither the V-A time. Ipsilateral (same side) bundle branch blocks increase the VA time and tachycardia cycle length.

VA increases to 180 ms. Panel (A) shows SVT with a narrow complex QRS. 105 180 RFW AP=Fixed TCL and VA Time w/ Narrow QRS RFW AP= +TCL and VA Time w/ RBBB . Panel (B) shows tachycardia with a RBBB. and the TCL to 425 ms. VA=105 ms. B. and a TCL=350 ms. A.RBBB during orthodromic AVRT using a R sided AP influences the VA interval and tachycardia cycle length.

Effects of Bundle Branch Block During Orthodromic Tachycardia Summary: Narrow QRS (HPS)= BL TCL and VA time Ipsilateral (same side) BBB= + TCL and VA time Contralateral (opposite side BBB)= no change TCL or VA time LBBB: RBBB: .

Classic Atrial Flutter .

.Atrial Flutter What is it? • Atrial flutter is a cardiac arrhythmia characterized by beat-to-beat uniformity of cycle length. and amplitude of the electrogram recordings. polarity. • Atrial rates usually 200-300 beats/min.

around anatomical obstacles. involving a large reentrant circuit localized within the right atrium. CS.Typical Atrial Flutter • Mechanism: Reentry. • Involves the TVA. ER and CSTA May be counterclockwise Or clockwise C S T A C S T A .

Counterclockwise Typical Atrial Flutter Typical Sawtooth Flutter Waves .

Intracardiac Electrograms of Typical Counterclockwise Atrial Flutter .

© C. . Bard. R. Inc.

© C. . Bard. Inc. R.

© C. Inc. Bard. . R.

Inc. .© C. Bard. R.

. R. Inc.© C. Bard.

© C. Bard. Inc. . R.

and inferior vena cava (the “isthmus”) • These conduction barriers are used as a guide to ablation. coronary sinus ostium. • Pacing from this area will entrain the tachycardia and prove the mechanism. then this is concealed entrainment.Typical Atrial Flutter • A zone of slow conduction exists between the tricuspid annulus. If the activation sequence during pacing is the same as flutter and the post pacing interval equals the tachycardia CL. .

in the case of flutter. IVC and area of functional block along the crista terminalis • Requires area of slow conduction that delays the impulse sufficiently such that it does not catch up with refractory tail of the preceding beat.Principles of entrainment to identify reentry circuit • An electrophysiologic technique in which pacing is used to continuously reset a reentrant circuit • Identifies a wavefront that rotates around an inexcitable obstacle which. . is the tricuspid valve.

Each paced impulse will advance the circuit— otherwise known as entrainment. and resetting it. slightly faster than the tachycardia cycle length.General Definition of Entrainment: A premature impulse invades the circuit during tachycardia • With correct timing. Consists of a continuous pacing train. and the orthodromic creating a new wavefront propagating via the tachycardia pathway. a paced impulse will divide in two. with the antidromic wavefront colliding with and extinguishing one portion of the original circuit. New circuit started here • .

QRS. QRS.Entrainment • The goal of entrainment is to determine the relationship of a given site to the reentrant circuit There are two types of entrainment: Concealed Entrainment: entrainment without fusion (No change in P wave. or IC morphology) • . or IC morphology) Manifest Entrainment: entrainment with fusion (A change in P wave.

or IC signal interval equal to the electrogram to P. QRS or IC interval during tachycardia .Criteria for concealed entrainment • P wave. or IC morphologies and activation sequences during pacing resemble those in tachycardia • A post-pacing interval within 20-30 msec of the tachycardia cycle length recorded at the pacing site • A stimulus to P. QRS. QRS.

Typical Atrial Flutter: Concealed Entrainment Pacing during flutter Post pacing interval=tachycardia cycle length .

Concealed Entrainment -PPI .

Concealed Entrainment No change in the morphology ECG 1 ECG 2 ECG 3 LEAD 1 LEAD 2 Pacing at a slightly faster rate Pacing at the critical site of the tachycardia .

Entrainment • Concealed: Pacing Site 1 3 2 .

QRS. or IC electrogram interval during pacing is not equal to the local electrogram to P.Criteria for manifest entrainment (with fusion) • P wave. or intracardiac morphologies and activation sequences during pacing do not resemble that of tachycardia • A post-pacing interval greater than the tachycardia cycle length by more than 20-30 msec recorded at the pacing site (the greater the PPI above the TCL. or IC interval in tachycardia . the farther from the circuit) • A stimulus to P. QRS. QRS.

Entrainment • With Fusion: Pacing Site 1 3 2 .

Manifest Entrainment (with fusion) .

Entrainment With Fusion Change in the morphology ECG 1 ECG 2 ECG 3 LEAD 1 LEAD 2 Pacing at a slightly faster rate Pacing at site non-critical to the tachycardia .

Typical Atrial Flutter • Atrial flutter is cured by performing a drag ablation from the tricuspid annulus to the eustachian ridge (IVC) • May also make additional line from TVA to CS or CS to ER • The goal is to connect non conducting tissues to form a barrier across the isthmus. .

Typical Atrial Flutter
• Pacing from the CS ostium is done when patient is not in flutter to show activation sequence.

CS pacing: No isthmus block pre ablation

Typical Atrial Flutter
• Pacing from the CS ostium is done after ablation to show unidirectional conduction block.
Clockwise block

• Pacing lateral to the ablation line will confirm bidirectional conduction block.
Counterclockwise block

Typical Atrial Flutter

© C. R. Bard, Inc.

What is happening? What is the activation sequence? What is the rhythm? What do you think of the surface EKG?

Typical Atrial Flutter

What is happening? What rhythm is on the left hand side of the tracing? What is happening to the right of the tracing?

Atrial Tachycardia

Atrial Tachycardia (A tach)
– Accounts for <5% of all SVTs – A tach is defined as an ectopic automatic atrial focus firing faster than the normal intrinsic rate of the sinus node – Usually has different P wave morphology than sinus, although may be similar if close to the SA node – Tend to be automatic in nature and are independent of the ventricle – Common sites are crista terminalis, cs os, pulmonary veins, and the tricuspid and mitral annuli (although may originate anywhere)

Atrial Tachycardia a tach sinus .

RSPV Atrial Tach PA View Earliest Mapping Site .

Atrial Tachycardia •Atrial tachycardia: More A signals than V .

Earliest Site: Pre P-Wave 45 ms 45ms .

Atrial Tachycardia What rhythm is shown here? Which “a” is earliest? Where may this tachycardia be coming from? .

Atrial Fibrillation .

Atrial Fibrillation (A Fib) – Among the most prevalent SVTs – Chaotic electrical pattern in the atria – Negates the physiologic benefit of AV synchrony – Foci from the pulmonary veins. Vein of Marshall. and other sources may serve as triggers for AF . SVC.

LSPV Mapping .

PV Mapping CS Pacing S A and PVP Fusion A PVP ∗ CS 3/4 .

Atrial Fibrillation: Chaotic Electrograms •Note the chaotic electrograms during a fib •There is no consistent activation sequence or cycle length .

Atrial Fibrillation What is this rhythm? What is the activation sequence? Where is the earliest “a”? .

Ventricular Tachycardias .

Differential Diagnosis for VT
•His-Purkinje System Tachycardias oBundle Branch Reentry Ventricular Tachycardia oVerapamil-Sensitive Left Ventricular Tachycardia oFocal His-Purkinje Tachycardia •Arrhythmogenic Right Ventricular Dysplasia •RVOT Ventricular Tachycardia •Right ventricular scar after surgical repair of congenital heart disease •Coronary artery disease with previous myocardial infarction •LVOT Ventricular Tachycardia •Verapamil-Sensitive Left Ventricular Tachycardia •VT associated with Tetralogy of Fallot Repair

Structurally Normal Heart VT
•LVOT Ventricular Tachycardia •RVOT Ventricular Tachycardia •Long QT Syndrome •Brugada syndrome •Catecholinergic VT • Verapamil-Sensitive LV VT

Ventricular Tachycardia (VT)
VT Features • VT originates from the ventricle • The atrium and AV node are dissociated from the ventricle • 2 types are idiopathic and ischemic • Idiopathic VT is from a normal heart, is focal, and is usually non-life threatening • Ischemic VT comes from coronary disease, is reentrant, and associated with an MI--tends to be more life threatening due to a low EF.

Strategy for Catheter Ablation of VT Focal Mechanism Target Tools Triggered Activity Automaticity Ablate Focus Macroreentry Intra myocardial Re entry Ablate Critical Pathway -Analysis of 12 lead ECG -Analysis of 12 lead ECG of VT of VT -Pace mapping -Pace mapping Response to pacing (PPI and CE) -Activation mapping -Activation mapping -Substrate Mapping (Voltage Mapping) .

other sites also possible – Associated with a normal heart.Idiopathic VT – Most commonly from RVOT. not reentrant – Pts typically receive ablation or medical therapy . usually benign – Reproducibility unpredictable with pacing: burst pacing may trigger as this is primarily an automatic rhythm.

IDIOPATHIC VENTRICULAR TACHYCARDIA RIGHT VENTRICLE LEFT VENTRICLE RVOT 80% PAROXYS MAL EXERCISE INDUCED FASCICLES 15% NON-SUSTAINED ANTERIOR POSTERIOR VT SUSTAINED VT RBBB RIGHT AXIS NARROW QRS RBBB LEFT AXIS NARROW QRS LBBB INFERIOR AXIS 5% other locations .

There is a left bundle branch pattern (QRS negative in V1) and an inferior axis (QRS positive in II. .Idiopathic RVOT VT from a young male with a normal heart. Independent P waves are not apparent. and AVF). III. The QRS is wide. and regular (.14 sec).

RVOT VT and Automaticity .

RVOT VT: Mapping Catheter in RVOT VA Dissociation Proves VT Mechanism .

RVOT VT: Mapping EGM –33 Early site in RVOT .

Clinical VT is on left. where pacing creates a perfect 12/12 perfect EKG pace map. the QRS appears progressively more similar to the target morphology: successful ablation occurred at site E. A-E show single paced complexes from five different sites attempting to match VT QRS. .Pacemapping RVOT VT. In A-D.

12/12 Pace Map: Side By Side Comparison Perfect Pace Map .

Where in the heart do you think it is coming from? .VT In a pt with a normal heart. this VT is induced.

Idiopathic Left Ventricular Tachycardia • Left Fascicular VT -reentry or triggered • Left Ventricular Outflow Tract VT -automatic .

Inferior Axis (+) II. . peaked QRS. RBBB morphology (+) V1. CL=290 ms.LVOT VT. II. Precordial leads are concordant with a positive. and AVF.

Epicardial .Left Ventricular Outflow Tract VT • • • • Three locations possible 1. Endocardial 2. Coronary cusp 3.

Ventricular ectopy arising from the base of the left coronary cusp.

Left Fascicular VT
• Also known as verapamil sensitive VT
Left Posterior fascicular VT with a RBBB and superior axis(common) Left Anterior fascicular VT with a RBBB and right axis(uncommon) Upper septal fascicular VT with a narrow QRS and normal axis(rare

• Young patients without heart disease • Posterior and anterior fascicular VT can be successfully ablated at the mid-septum guided by a diastolic Purkinje potential or at the VT exit site guided by a fused pre-systolic Purkinje potential

Left Posterior Fascicular VT

Right bundle (positive (+) V1) superior axis (II, III, and AVF negative (-))

Left Posterior Fascicular VT Fused pre-systolic Purkinje potential .

Ischemic VT • • • • Induced with PES Re-entry in nature RF is second line therapy Stable Vs Unstable VT .

Ischemic VT What is happening here? What is the rhythm? Is there association between the A and V? What is the activation sequence? .

Ischemic VT .

Ischemic VT a a v v v .

Ischemic VT – Associated with scar from a myocardial infarction through which a reentry circuit rotates – 90% inducible in EP lab with programmed stimulation – Pts typically receive ICD/ablation is 2nd line therapy for patients receiving frequent shocks VT circuit in scar .

5 mV .5 mV.5 –1.Substrate Mapping . dense scar Marchilinski et al Circ 2000. border zone • EGM amplitude < 0.Voltage • EGM amplitude > 1.5 mV . Reddy 2004 . normal myocardium • EGM amplitude 0.

37% Vs SPECT Imaging .LV .5mV LV .PA LV .BOTTOM 980528RM Endocardial Scar / Infarct Size: Magnetic Mapping .50mV LV .LAO < 0.36% .RAO >1.

Ischemic VT: Scar Voltage Mapping .

then the area is tagged as scar • Can be used to identify borders of low voltage infarct regions and borders of infarct zones • Can identify areas that will NOT respond to RF as they are already electrically inert .Electrically Unexcitable Scar • Pace at 10 mA unipolar from map catheter • If there is failure to capture.

Ventricular Tachycardia .

is focal. and is usually non-life threatening • Ischemic VT comes from coronary disease. is reentrant. . and associated with an MI--tends to be more life threatening due to a low EF.Ventricular Tachycardia (VT) VT Features • VT originates from the ventricle • The atrium and AV node are dissociated from the tachycardia • AV dissociation is often seen during VT • 2 types are idiopathic and ischemic • Idiopathic VT is from a normal heart.

Ischemic VT – Most common type of VT – Usually LV. life threatening if EF is low – Associated with scar from a myocardial infarction through which a reentry circuit rotates – 90% inducible in EP lab with programmed stimulation – Pts typically receive ICD/ablation is 2nd line therapy for patients receiving frequent shocks VT circuit in scar .

Ischemic VT .

Ischemic VT a a v v v .

Ischemic VT: Scar Voltage Mapping .

Ablation in such a site may successfully result in VT termination.Electrogram recorded from the LV endocardium during VT in a patient with a prior MI. . This potential presumably reflects activation of a zone of slow conduction. A isolated low amplitude mid-diastolic potential precedes local ventricular activation by approximately 150-160 ms.

Ischemic VT What is happening here? What is the rhythm? Is there association between the A and V? What is the activation sequence? .

usually benign – Reproducibility unpredictable with pacing: burst pacing may trigger as this is primarily an automatic rhythm. not reentrant – Pts typically receive ablation or medical therapy . other sites also possible – Associated with a normal heart.Idiopathic VT – Represents the minority of all VTs – Most commonly from RVOT.

IDIOPATHIC VENTRICULAR TACHYCARDIA IDIOPATHIC VENTRICULAR TACHYCARDIA RIGHT VENTRICLE RIGHT VENTRICLE LEFT VENTRICLE LEFT VENTRICLE RVOT RVOT 80% PAROXYS MAL PAROXYS MAL EXERCISE INDUCED EXERCISE INDUCED FASCICLES FASCICLES 15% NON-SUSTAINED NON-SUSTAINED RMVT RMVT ANTERIOR ANTERIOR POSTERIOR POSTERIOR SUSTAINED VT SUSTAINED VT LBBB LBBB INFERIOR AXIS INFERIOR AXIS RBBB RBBB RIGHT AXIS RIGHT AXIS NARROW QRS NARROW QRS RBBB RBBB LEFT AXIS LEFT AXIS NARROW QRS NARROW QRS 5% other locations .

. Independent P waves are not apparent.14 sec).Idiopathic RVOT VT from a young male with a normal heart. There is a left bundle branch pattern (QRS negative in V1) and an inferior axis (QRS positive in II. The QRS is wide. III. and regular (. and AVF).

RVOT VT and Automaticity .

RVOT VT: Mapping Catheter in RVOT VA Dissociation Proves VT Mechanism .

RVOT VT: Mapping EGM –33 Early site in RVOT .

.Pacemapping RVOT VT. In A-D. Clinical VT is on left. A-E show single paced complexes from five different sites attempting to match VT QRS. the QRS appears progressively more similar to the target morphology: successful ablation occurred at site E. where pacing creates a perfect 12/12 perfect EKG pace map.

12/12 Pace Map: Side By Side Comparison Perfect Pace Map .

VT In a pt with a normal heart. Is is ischemic or idiopathic? Where in the heart do you think it is coming from? . this VT is induced.

Bundle Branch Reentrant Ventricular Tachycardia .

VT From Bundle Branch Reentry • Occurs in up to 30% of VT associated with idiopathic dilated cardiomyopathy • VT is usually left bundle branch block (negative QRS in V1). III. superior axis (negative QRS in II. and AVF) morphology .

VT From Bundle Branch Reentry • Dependent on both bundles for reentry • Baseline EKG usually will demonstrate signs of underlying conduction delay (bundle branch block) and signs of cardiac dilatation (atrial enlargement) Goals: Ablate right bundle and abolish reentry .

Baseline Sinus EKG in BBRVT The baseline sinus rhythm EKG demonstrates a classic LBBB (wide negative QRS in V1>120 ms) with left atrial enlargement as seen with a large negative component to the P wave in V1 and a very broad P wave in lead II. .

. III.VT Due to Bundle Branch Reentry The EKG of bundle branch reentry VT demonstrates a left bundle branch block pattern (wide negative QRS in V1) with a superior axis (negative QRS in II. and AVF).

but conducts up the left bundle branch into the His Bundle.VT Due to Bundle Branch Reentry The typical induction method for BBRVT is with single premature beats from the right ventricle. His Bundle Right Bundle Branch Left Bundle Branch . a single premature beat (S) blocks retrograde in the right bundle branch. Here.

the right bundle has recovered and the impulse then travels antegrade down the right bundle branch. then back up the left bundle. the premature beat may block in the left bundle retrograde and set up a circuit in the reverse direction with a RBB pattern (wide positive QRS in V1) . initiating the reentry circuit of bundle branch reentry with a LBBB pattern.VT Due to Bundle Branch Reentry Often. His Bundle Right Bundle Branch Left Bundle Branch In rare instances. by the time the impulse gets up the left bundle and through the His. The His is part of the circuit and a 1:1 relationship is observed between the His and V during VT.

.

In this example the baseline HV is slightly prolonged at 65 ms.Baseline HV in BBRVT It is quite typical to observe a baseline prolonged HV interval in patients with BBRVT during sinus rhythm. .

the EKG during BBRVT shows a similar QRS morphology as compared to the baseline sinus EKG: a classic LBBB. . With careful inspection. VA dissociation may also be observed at the rhythm strip on the bottom as P waves march through the QRS.VT EKG in BBRVT Interestingly.

VA Dissociation in BBRVT During BBRVT. there is a left bundle branch pattern and a dissociation between the V and A signals.The atrial dissociation demonstrates the atrium is not part of the circuit. they are high to low. The A signals are not only dissociated as they march through the VT. Negative QRS (LBB pattern) in V1 during VT HRA The As “Walk Through” The Vs The Atrial Activation is High to Low . denoting a sinus origin.

each V is preceded by a His signal denoting the His is part of the circuit. HRA HV Interval=110 ms Each V is preceded by a His The third His is obscured by the dissociated A . This is diagnostic for BBRVT.V-His Association in BBRVT While the A is dissociated. is classically > 100 ms. as seen here. the HV in BBRVT. In addition.

Note that the RBB spike occurs well after the His spike. elimination of the RBB will eliminate the VT. which is the site of ablation for this tachycardia. Given this patient’s underlying LBBB. but leaves the patient with AV conduction totally relying on the LBB. . In this patient. they may likely need a pacer post ablation.Site of Ablation in BBRVT The ablation catheter is positioned at the right bundle branch during sinus rhythm.

Post RBB Ablation Successful ablation of the right bundle in a patient with BBRVT. Now the patient requires a permanent pacemaker. . Notice the P waves without QRSs following. Now that the patient can no longer have BBRVT. the RBB ablation. in conjunction with underlying LBBB has resulted in complete heart block.

this patient can no longer have BBRVT. leaves the patient with a permanent right bundle branch block (wide positive QRS in V1) in sinus rhythm. but I rather.II Now that the the right bundle is ablated. This patient will probably not require a pacemaker V1 RA Current Voltage .Post RBB Ablation Successful ablation of the right bundle in another patient does not cause complete heart block.

. • The site of the RBB potential can be demarcated for ablation.Bundle Branch Reentry and CARTO® XP System • Bundle branch reentry VT ablation with CARTO® XP System is anatomical.

• Other sites of interest for anatomy may be delineated but are not essential. .Bundle Branch Reentry and CARTO® XP System • His bundle can also be marked as to not cause inadvertent heart block. • The tricuspid valve should be marked.

Right Bundle Branch Location The right bundle branch lies just distal to the His Bundle below the tricuspid valve on the superior aspect of the interventricular septum. .

Site of RBB for BBRVT Ablation (with CARTO® XP System) in RAO RVOT His His Potential RBB Site on Interventricular Septum just distal to the His (Successful Ablation) RVA RV RAO for anatomic representation of the right bundle branch location TVA RBB Potential .

Idiopathic Left Ventricular Tachycardia • Left Fascicular VT -reentry or triggered • Left Ventricular Outflow Tract VT -automatic .

Left Fascicular VT • Also known as verapamil sensitive VT Left Posterior fascicular VT with a RBBB and superior axis(common) Left Anterior fascicular VT with a RBBB and right axis(uncommon) Upper septal fascicular VT with a narrow QRS and normal axis(rare) • Young patients without heart disease • Posterior and anterior fascicular VT can be successfully ablated at the mid-septum guided by a diastolic Purkinje potential or at the VT exit site guided by a fused pre-systolic Purkinje potential. .

and AVF negative (-)) .Left Posterior Fascicular VT Right bundle (positive (+) V1) superior axis (II. III.

Left Posterior Fascicular VT Fused pre-systolic Purkinje potential .

Left Ventricular Outflow Tract VT • • • • Three locations possible 1. Endocardial 2. Epicardial . Coronary cusp 3.

Ventricular ectopy arising from the base of the left coronary cusp. .

. and AVF. Precordial leads are concordant with a positive. RBBB morphology (+) V1. peaked QRS. Inferior Axis (+) II. CL=290 ms. II.LVOT VT.

Limitations of EUS Technique • Many labs are unfamiliar with Unipolar pacing • Requires a IVC electrode • Noise on Map catheter with Unipolar pacing interferes with entrainment pacing measurements • Requires significant confidence in contact of catheter with myocardium .

2002 • • .Pace Mapping • Well established technique for Idiopathic VTs but less reliable for ischemic VTs A perfect pace match may not be achievable with scar related tachycardia 12/12 pace map represents exit site of arrhythmia Azegami et al. Pacing Clin Electrophysiol.

5mV .5-.Example of(LBB LSa) VT # 1 Pace Mapping Best PM RAO LV post/mid septum inferior Bipolar voltage map 1.

Barrier only present in AT SOO VT. QRS changes 200ms 520ms 460ms 460ms .Functional Barrier During VT Only ENTRAINMENT No QRS changes during DURING VT pacing PACING .NSR Trans-barrier conduction during pacing.

Entrainment Mapping • Pace from map catheter during VT at slightly faster rate than VT rate • Entrainment with Concealed fusion Vs Manifest fusion • Stimulus to QRS should equal local EGM to QRS during VT (within 10 msec) .

= Stim-QRS = EGM-QRS Egm-QRS .

J Am Coll Cardiol 2003. Restrictions may apply. et al. S.42:110-115 Copyright ©2003 American College of Cardiology Foundation. .Entrainment of ventricular tachycardia (VT) at a site with a double potential is shown Tung.

Brunckhorst et al. Circ 2004 . infarct zone • Sites with short S-QRS are likely at exit site C.Stim to QRS During Pace Map • Provides a measure of slow conduction when Stim to QRS > 40 msec • Sites with long S-QRS delays are likely in potential isthmus.

Stim to QRS .

ENTRAINMENT MAPPING Pacing During VT Entrain with QRS fusion (QRS change) Entrain with Concealed Fusion (CF) * er L Out * oop * PPI = VTCL ± 30 ms or S – QRS = EG-QRS ± 20 ms No Yes PPI = VTCL ± 30 ms Is t * mus h r nt E e nc a Adjacent Bystander S – QRS / VTCL (%) Exit < 30% Inner Loop 31-50% Central 51-70% Proximal >70% Inner Loop * Exit * *Adjacent bystander * * * No Remote Bystander Yes Outer Loop *Remote bystanders .

Hwang. Europace 2003 .Targeting Late Potentials in NSR C.

Activation Map • Is useful to identify the entire circuit • Can identify areas of slow conduction • Success of ablation is independent on speed of conduction through protected isthmus • Useful to identify double loops of reentry .

.

Electrograms During VT er L Out o op Is *mus th an tr En ce Exit Inner Loop * * .

Mid Diastolic Potentials During VT • Map potentials which precede QRS by > 50 msec • Potentials must be shown to correlate during NSR to VT potentials .

.Mid Diastolic Potentials in VT .

Europace 2003 .Hwang.C.

Putting It All Together • Linear lesions along border of scar to closest pace map match (exit point) • Target late potentials in NSR • Target mid-diastolic potentials during VT • Linear lesions connecting scar to scar or scar to anatomical boundaries .

MD et al.Kyoko Soejima. Circ 2002 .

.

Bundle Branch Reentrant Ventricular Tachycardia .

III. superior axis (negative QRS in II. and AVF) morphology .VT From Bundle Branch Reentry • Occurs in up to 30% of VT associated with idiopathic dilated cardiomyopathy • VT is usually left bundle branch block (negative QRS in V1).

VT From Bundle Branch Reentry • Dependent on both bundles for reentry • Baseline EKG usually will demonstrate signs of underlying conduction delay (bundle branch block) and signs of cardiac dilatation (atrial enlargement) Goals: Ablate right bundle and abolish reentry .

Baseline Sinus EKG in BBRVT .

VT EKG in BBRVT .

VT Due to Bundle Branch Reentry .

VT Due to Bundle Branch Reentry His Bundle .

VT Due to Bundle Branch Reentry His Bundle Right Bundle Branch Left Bundle Branch .

.

Baseline HV in BBRVT .

V-His Association in BBRVT HRA HV Interval=110 ms Each V is preceded by a His The third His is obscured by the dissociated A .

Site of Ablation in BBRVT .

Post RBB Ablation .

Post RBB Ablation I II V1 RA Current Voltage .

Sign up to vote on this title
UsefulNot useful

Master Your Semester with Scribd & The New York Times

Special offer: Get 4 months of Scribd and The New York Times for just $1.87 per week!

Master Your Semester with a Special Offer from Scribd & The New York Times