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Differential Diagnoses Of SVT: Common EP Lab Techniques

Differential Diagnoses Of SVT: Common EP Lab Techniques. Hongsheng M. Guo, MD Park Nicollet Heart & Vascular Center Minnesota, USA. SVT Ablations at Park Nicollet (2006-2010). N=1205. N=545. Systematic Approaches. Baseline findings Tachycardia Maneuvers during tachycardia History.

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Differential Diagnoses Of SVT: Common EP Lab Techniques

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  1. Differential Diagnoses Of SVT:Common EP Lab Techniques Hongsheng M. Guo, MD Park Nicollet Heart & Vascular Center Minnesota, USA

  2. SVT Ablations at Park Nicollet(2006-2010) N=1205 N=545

  3. Systematic Approaches • Baseline findings • Tachycardia • Maneuvers during tachycardia • History

  4. Baseline Findings

  5. HV = -15 ms PPV for ORT=86%

  6. AH Jump PPV for AVNRT=86%

  7. Decremental VA Conduction >99% Nodal Respnse

  8. RV Pacing at 700 ms PPV for ORT, 5%

  9. Adenosine

  10. ParaHisian Pacing

  11. AP Response

  12. ParaHisian Pacing

  13. ParaHisian Pacing • Adjust current output (mA) • Adjust catheter position • Watch morphology subtle change closely

  14. ParaHisian Pacing Source: Heart Rhythm 2005; 2:667-672 (DOI:10.1016/j.hrthm.2005.01.026 )

  15. ParaHisian Pacing: Nodal Response

  16. ParaHisian: AP Response PPV for ORT, 83%

  17. Differential RV Pacing VA Index= VA (basal) – VA (apical) Martinez-Alday, et al Circulation 1994;89:1060

  18. Differential RV Pacing: Nodal Response

  19. Posteroseptal AP Martinez-Alday, et al Circulation 1994;89:1060

  20. Systematic Approaches • Baseline findings • Tachycardia • Maneuvers during tachycardia • History

  21. Tachycardia Characteristics

  22. Septal VA <70 ms Not ORT

  23. Eccentric Atrial Activation Not AVNRT

  24. SVT: What’s the machanism? • AT • ORT • AVNRT • Not sure.

  25. What is this?

  26. Quick Maneuver

  27. SVT: What’s the mechanism? • AT • ORT • AVNRT • Not sure.

  28. Systematic Approaches • Baseline findings • Tachycardia • Maneuvers during tachycardia • History

  29. RA Pacing During SVT

  30. LA (CS) Pacing During SVT

  31. RV Pacing During SVT

  32. What is this patient trying to tell you?

  33. SVT Induction

  34. Which Statement is true? • VA activation is eccentric. • This is likely ORT. • AV accessory pathway is ruled out. • AV accessory pathway is not ruled out.

  35. His Refractory PVC

  36. His Refractory PVC

  37. RV Pacing During SVT

  38. True or not: Atrial tachycardia is ruled out? A. True. B. False.

  39. RV Pacing

  40. RV Pacing: AT?

  41. Is This AT?

  42. Fusion During Right ORT Source: Heart Rhythm 2011; 8:2-7 (DOI:10.1016/j.hrthm.2010.09.089 )

  43. Fusion During Left Lateral ORT and AVNRT Source: Heart Rhythm 2011; 8:2-7 (DOI:10.1016/j.hrthm.2010.09.089 )

  44. Fusion During ORT Source: Heart Rhythm 2011; 8:2-7 (DOI:10.1016/j.hrthm.2010.09.089 )

  45. Fusion During AVNRT Source: Heart Rhythm 2011; 8:2-7 (DOI:10.1016/j.hrthm.2010.09.089 )

  46. Long RP SVT Michaud, G. F. et al. J Am Coll Cardiol 2001;38:1163-1167 Scatterplot showing the mean value {+/-} SD of the stimulus-atrial-ventriculo-atrial (S-A-VA) interval (ms) for patients with either ORT using a septal accessory pathway or atypical AVNRT

  47. Long RP SVT Michaud, G. F. et al. J Am Coll Cardiol 2001;38:1163-1167 Scatterplot showing the mean value {+/-} SD of PPI-TCL (ms) for patients with either ORT using a septal accessory pathway or atypical AVNRT

  48. RV Is In The SVT Circuit Michaud, G. F. et al. J Am Coll Cardiol 2001;38:1163-1167 Entrainment of orthodromic reciprocating tachycardia (ORT) using a right posteroseptal bypass tract from the right ventricular apex (RVA) at a cycle length of 440 ms

  49. RV Is Not In The SVT Circuit Michaud, G. F. et al. J Am Coll Cardiol 2001;38:1163-1167 Entrainment of atrioventricular node re-entrant tachycardia (AVNRT) from the right ventricular septum (RVS) at a cycle length of 510 ms

  50. Entrainment Mapping B A>B>E m m TCL=24 hours PPI=24 + 2xm hours A

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