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16-09-2016 | Rhythm Puzzle - Answer | Uitgave 1/2017 Open Access

Netherlands Heart Journal 1/2017

Regular, narrow QRS, long RP tachycardia – what is the mechanism?

Tijdschrift:
Netherlands Heart Journal > Uitgave 1/2017
Auteurs:
S. Tzeis, S. Pastromas, A. Sikiotis, G. Andrikopoulos

Answer

The differential diagnosis of a regular, narrow QRS, long-RP tachycardia includes atypical atrioventricular nodal reentry tachycardia (AVNRT), atrial tachycardia and atrioventricular reentry tachycardia (AVRT) via a slowly conducting accessory pathway usually presenting decremental conduction properties.
Ventricular overdrive pacing is the proposed initial diagnostic manoeuvre. During ventricular overdrive pacing the following criteria are assessed: (A) post-pacing response (V-A-V versus V‑A-A-V) and (B) post-pacing interval (PPI) minus tachycardia cycle length (TCL). A V-A-A-V response strongly suggests atrial tachycardia, while a V-A-V response is encountered in both AVRT and AVNRT [ 1]. The PPI-TCL differentiates an atypical AVNRT from an AVRT with a discriminant value of 115 msec (>115 msec suggests atypical AVNRT, while <115 msec an AVRT) [ 2].
In our case, ventricular overdrive pacing resulted in consistent retrograde atrial capture, V‑A-V post-pacing response, with a PPI-TCL of 64 msec which led to the diagnosis of an AVRT (Fig.  1). During mapping, the earliest retrograde atrial activation was identified in a coronary sinus branch, suggestive of a coronary sinus-ventricular accessory pathway (Fig.  2) [ 3]. Ablation in the area of retrograde atrial prematurity with an irrigating catheter (20 W) resulted in tachycardia termination. Successful ablation was validated by post-ablation para-Hisian pacing, which showed a nodal response and adenosine administration during ventricular pacing.
The diagnosis of an AVRT using a slowly conducting accessory pathway should be taken into consideration in the differential diagnosis of a regular, narrow QRS, long-RP tachycardia even among patients with a first presentation within middle adulthood and an episodic occurrence on Holter recording, suggestive of an atrial tachycardia.
Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://​creativecommons.​org/​licenses/​by/​4.​0/​), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

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Netherlands Heart Journal

Het Netherlands Heart Journal wordt uitgegeven in samenwerking met de Nederlandse Vereniging voor Cardiologie en de Nederlandse Hartstichting. Het tijdschrift is Engelstalig en wordt gratis beschikbaa ...

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