Dr Julian Johny Thottian DM Cardiology Resident Govt. Medical
College, Kozhikode
Slide 2
ANATOMY ANATOMY OF VARIOUS ACCESSORY PATHWAYS OBLIQUE VIEW OF
RT ATRIUM SHOWING RE ENTRANT PATHWAY IN ATRIAL FLUTTER
Slide 3
ANATOMY OF KOCH`S TRIANGLE
Slide 4
PAC AND CONDUCTION PAC SINGLE/REPETITIVE OR UNIFOCAL /
MULTIFOCAL IN ORIGIN FATES OF PAC DEPENDS UPON 1) Coupling interval
from the last P wave 2) Preceding cycle length or Heart rate.
Slide 5
BASIC UNDERSTANDING OF PAC
Slide 6
What`s a supraventricular tachycardia? Heart rhythm disturbance
Initiated either in atria or ventricle Atrial rates > 100bpm
Requires a tissue above the His bundle to perpetuate it. NARROW
COMPLEX TACHCARDIA A TACHYCARDIA WITH QRS WIDTH
PAROXYSMAL- Recurrent episodes( 2 or more)that terminate within
7 days of onset PERSISTENT- Episodes that last for more then 7 days
or require cardioversion regardless of duration LONG STANDING
PERSISTENT AF- Continuous episodes of persistent AF for> 1yr
PERMANENT Restoration and maintenance of sinus rhythm has failed or
not attempted. An episode---Should last for 30s - clinical AF Fine
AF- f waves 0.5mv
Slide 12
Ashman phenomenon- follows a long short sequence Gouaux, JL;
Ashman, R (Sep 1947). "Auricular fibrillation with aberration
simulating ventricular paroxysmal tachycardia.". American heart
journal 34 (3): 36673
Slide 13
ATRIAL FLUTTER RENTRANT TACHY USUALLY FROM RT ATRIUM ATRIAL
RATE -200-350BPM TYPE 1 TERMINATED BY ATRIAL PACING, ATRIAL RATE
UPTO 240 TYPE II- CANNOT BE TERMINATED BY ATRIAL PACING ATRIAL RATE
BETWEEN 240-330/MT MC COUNTERCLOCKWISE- SAW TOOTHED APPEARANCE IN
II, III, AVF/ NO ISO ELECTRIC SEGMENT IN BETWEEN- 90% 10%-
CLOCKWISE ATYPICAL FORMS- LOWER/UPPER LOOP RE ENTRY/ FIGURE OF
EIGHT RE ENTRY
Slide 14
Slide 15
ATRIAL TACHYCARDIA ORIGINATE- LT,RT ATRIUMS/ VENA CAVAE/PV
FOCAL- TRIGGERED/MICROREENTRANT/AUTOMATIC P OF DIFFERENT MORPHOLOGY
PR VARIES ATRIAL RATES- 120-200BPM 1:1 CONDUCTION/AV BLOCK
ADENOSINE CAN OCCASIONALLY STOP TACHY DIGOXIN TOXICITY- AT WITH AV
BLOCK
Slide 16
Slide 17
Focal atrial tachycardia (LA focus)
Slide 18
Focal Atrial tachycardia AUTOMATIC AT- GRADUAL ONSET(WARM
UP)/OFFSET MAY NOT START WITH PREMATURE BEAT P WAVE DIFFERENT
CONFUSION WITH ST & ASSOC ADENOSINE INSENSITIVITY TRIGGERED
WITH ISOPROTERENOL & NOT WITH PROGRAMMED STIMULATION RAPID
STIMULATION MAY NOT INITIATE THE TACHYCARDIA TRIGGERED AT SUDDEN
ONSET/OFFSET ASSOC WITH RAPID PACING, DAD?? ADENOSINE TERMINATION
CATECHOLAMINE DEPENDENT PERSISTENT TACHY- CARDIOMYOPATHY MICRO
ENTRY AT- TERMINATION WITH VERAPAMIL,INITATED AND TERMINATED BY
PACING
Slide 19
Intra Atrial re entrant tachycardia MACRO/MICRO REENTRY- SCAR
INCISIONS LIKE FONTAN DISCRETE P WAVES AND ISO ELECTRIC BASELINE
ADENOSINE MAY TERMINATE-15% CASES
Slide 20
SANRT MICROREENTRANT TACHYCARDIA P WAVE MORPHOLOGY SIMILAR
USUALLY PRECIPITATED AND TERMINATED BY PREMATURE ATRIAL COMPLEXES.
ATRIAL RATE IS USUALLY 120-150 BPM. STOPS AND STARTS ABRUPTLY AV
BLOCK CAN OCCUR.
Slide 21
MULTIFOCAL ATRIAL TACHYCARDIA ALSO KNOWN AS CHAOTIC ATRIAL
TACHYCARDIA ACTIVATION FROM MULTIPLE PLACES ATLEAST 3 DIFFERENT P
WAVE MORPHOLOGIES ISOELECTRIC BASELINE BETWEEN P WAVES ATRIAL RATE
-110-170BPM COPD,ELDERLY,SEPSIS,HT EXACERBATED BY THEOPHYLLINE
Slide 22
Multifocal Atrial Tachycardia
Slide 23
AV NODAL REENTRANT TACHYCARDIA
Slide 24
AVNRT PRESENCE OF 2 PHYSIOLOGICAL/ANATOMICAL AV NODAL PATHWAYS
65% OF REGULAR SVT ACTIVATION- VIA SLOW FIRST THEN FAST RATES
150-200BPM BEGINS WITH PREMATURE ATRIAL DEPOLARISATION PSEUDO R`-
V1,PSEUDO S-II III AVF W>M MORE IN ADULTS STOPS WITH VAGAL
MANEUVRES ABRUPTLY
Slide 25
AVNRT NO P waves P waves are retrograde and are inverted in
leads II,III,AVF. P waves are buried in the QRS complexes
simultaneous activation of atria and ventricles most common
presentation of AVNRT 66%. If not synchronous pseudo s wave in
inferior leads,pseudo r wave in lead V1---30% cases. P wave may be
farther away from QRS complex distorting the ST segment
---AVNRT,mostly AVRT.
Slide 26
Slide 27
Slide 28
Slide 29
Slide 30
AVRT Typical RP interval < PR interval RP interval > 80
milli sec Atypical RP interval > PR interval Concealed bypass
tract only retrograde conduction Manifest bypass tract both
anterograde and retrograde. Electrical alternans the amplitude of
QRS complexes varies by 5 mm alternatively. Rate related BBB
occuring and the rate of tachycardia is decreasing then the bypass
tract is on the same side of the block.
Slide 31
AV REENTRANT TACHYCARDIA
Slide 32
Slide 33
Slide 34
Slide 35
AVRT MACRO RE ENTRANT CIRCUIT TYPICAL- ANTEGRADE AV NODE
RETROGRADE VIA ACCESSORY PATHWAY- ORTHODROMIC -30% REGULAR SVT QRS
ALTERNANS CAN BE CONCEALED/MANIFEST DELTA WAVE STOPS WITH VAGAL
MANEUVRES ABRUPTLY
Slide 36
PRE EXCITATION SYNDROMES WPW PATTERN-MANIFEST ANTEGRADE
CONDUCTION THROUGH AP-PRE EXCITE THE VENTRICLE-WPW PATTERN ASSOC
WITH PALPITATIONS WPW SYNDROME ORTHODROMIC SVT IS THE MOST COMMON
IN 10% ANTEGRADE CONDUCTION VIA AP
Slide 37
WPW syndrome Two types Orthodromic Antidromic Antidromic is
wide complex tachycardia In NSR detected by delta wave. Can ppt AF
and VF on use of AV nodal blockers MEMBRANE ACTIVE ANTIARRHTYHMIC
DRUGS are safe. CONCEALED WPW syndrome no delta wave.less risk of
AF
Slide 38
Slide 39
Slide 40
Orthodromic AVRT
Slide 41
OTHER PRE EXCITATIONS MAHAIM- ATRIOFASCICULAR PATHWAY CONNECTS
ATRIUM TO RT BUNDLE BYPASSING AV NODE DECREMENTAL PROPERTIES SHORT
PR WITH NO MANIFEST PRE EXCITATION LAD & LBBB- RA TO RT BUNDLE
MAHAIM CONDUCT IN ANTEROGRADE DIRECTION ONLY
Slide 42
PERMANENT JUNCTIONAL RECIPROCATING TACHYCARDIA PJRT- PERSISTENT
AVRT CONDUCTION VIA AV NODE>> POSTEROSEPTAL SLOW AP LONG RP
TACHCARDIA P FAR AFTER QRS
Slide 43
PJRT
Slide 44
JUNCTIONAL ECTOPIC TACHYCARDIA AUTOMATIC / TRIGGERED ORIGINATES
AROUND AV NODE PERSISTENT RHYTHM DOESNOT GENERALLY TERMINATE WITH
ADENOSINE CHILDREN POST CARDIAC SX, AMI, CARDIOVERSION OF AF,
MYOCARDITIS,DIGOXIN TOXICITY SVT WITH AV DISSOCIATION
Slide 45
DIAGNOSIS ABRUPT RAPID PALPITATIONS DIZZINESS SYNCOPE WITH VERY
FAST RATE DYSPNOEA CHEST DISCOMFORT RELIEF WITH VAGAL MANEUVRES
CANNON WAVES- TYPICAL AVNRT IRREGULAR PULSE,PULSE DEFICIT> 10 IN
AF
Slide 46
Slide 47
Slide 48
Slide 49
ECG findings
Slide 50
Slide 51
Slide 52
Slide 53
Slide 54
Slide 55
Slide 56
Slide 57
2. MODE OF INITIATION
Slide 58
MODE OF INITIATION
Slide 59
Slide 60
MODE OF INITITIATION-AVRT
Slide 61
1.Spontaneous change in cycle length 2.No definite PR jump
3.Change in P wave morphology
Slide 62
3. MODE OF TERMINATION
Slide 63
Slide 64
Slide 65
Slide 66
4.MORPHOLOGY OF P WAVES P waves in lead Avl- Positive or
biphasic (negative-positive) -Right Atrial Focus (Right to left
activation) P waves in lead aVL- Negative or isoelectric: Left
atrial focus P waves in V1 Positive (Posterior to anterior/
left-to-right activation): Left atrial focus Negative or biphasic
(anterior to posterior/ right-to-left activation): Right atrial
focus P waves in inferior leads Positive (High to low activation):
HRA/ High LA Negative (Low to high activation): Retrograde P in
AVNRT, AVRT or AT with low atrial focus (e.g. CS/ low CT)
Slide 67
P wave morphology contd Clockwise Flutter waves ve in inferior
leads & V6 & +ve in V1 Counter clockwise Typical A Flutter:
Positive P waves in II/III/aVF, Biphasic F wave in I, aVL, V1
Upright F wave in V6
Slide 68
5.MORPHOLOGY OF QRS
Slide 69
6.VARIATION IN CYCLE LENGTH
Slide 70
Slide 71
Slide 72
7. RESPONSE TO VALSALVA & AV BLOCKER
Slide 73
7.EFFECT OF BBB & AVB
Slide 74
NCT DIAGNOSTIC FEATURES AV RATIO- >1 (A>V)-AT, AFL,
AVNRT(rare) A=V- AVNRT, AVRT, AT, JT
