Koichi Nagashima1, Yoshiaki Kaneko2, Mitsunori Maruyama3, Akihiko Nogami4, Shinya Kowase5, Hitoshi Mori6, Naokata Sumitomo6, Seiji Fukamizu7, Rintaro Hojo7, Takeshi Kitamura7, Kyoko Soejima8, Akiko Ueda9, Takayuki Otsuka10, Mitsuru Takami11, Kojiro Tanimoto12, Tetsuya Asakawa13, Kenta Kumagai14, Shuntaro Tamura2, Hiroshi Hasegawa2, Kazuyoshi Ogura15, Mitsuharu Kawamura16, Yumi Munetsugu16, Morio Shoda17, Satoshi Higuchi17, Hisanori Kanazawa18, Shigeki Kusa19, Akira Mizukami20, Shinsuke Miyazaki21, Yuji Wakamatsu22, Yasuo Okumura22. 1. Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Ibaraki, Tokyo, Japan. Electronic address: cocakochan@gmail.com. 2. Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan. 3. Department of Cardiovascular Medicine, Nippon Medical School Musashikosugi Hospital, Tokyo, Japan. 4. Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan; Department of Heart Rhythm Management, Yokohama Rosai Hospital, Yokohama, Kanagawa, Japan. 5. Department of Heart Rhythm Management, Yokohama Rosai Hospital, Yokohama, Kanagawa, Japan. 6. Department of Pediatric Cardiology, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan. 7. Department of Cardiology, Tokyo Metropolitan Hiroo Hospital, Shibuya, Tokyo, Japan. 8. Department of Cardiovascular Medicine, Kyorin University Hospital, Mitaka, Tokyo, Japan. 9. Division of Advance Arrhythmia Management, Kyorin University Hospital, Mitaka, Tokyo, Japan. 10. Department of Cardiovascular Medicine, The Cardiovascular Institute, Kobe, Japan. 11. Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan. 12. Department of Cardiology, Tokyo Medical Center, Tokyo, Japan. 13. Department of Cardiology, Yamanashi Kosei Hospital, Yamanashi, Japan. 14. Department of Cardiology, Odawara Cardiovascular Hospital, Odawara, Japan. 15. Division of Cardiovascular Medicine, Endocrinology and Metabolism, Department of Molecular Medicine and Therapeutics, Faculty of Medicine, Tottori University, Tottori, Japan. 16. Division of Cardiology, Showa University School of Medicine, Tokyo, Japan. 17. Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan. 18. Department of Cardiac Arrhythmias, Kumamoto University Hospital, Kumamoto, Japan. 19. Division of Cardiology, Tsuchiura Kyodo Hospital, Tsuchiura, Japan. 20. Department of Cardiology, Kameda Medical Center, Kamagawa, Japan. 21. Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan. 22. Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Ibaraki, Tokyo, Japan.
Abstract
OBJECTIVES: This study sought to assess the performance of current diagnostic criteria and identify additional electrophysiological features differentiating orthodromic reciprocating tachycardia (ORT) with a concealed nodoventricular/nodofascicular (NV/NF) pathway from atrioventricular nodal re-entrant tachycardia (AVNRT). BACKGROUND: Diagnosing sustained supraventricular tachycardia (SVT) despite the occurrence of ventriculoatrial block (VAB) is challenging. METHODS: We analyzed electrograms of 25 sustained SVTs (9 NV/NF-ORTs [n = 7/2] and 16 AVNRTs) with VAB and 91 AVNRTs without VAB (for reference). RESULTS: More than 1 SVT, each with a different ventriculoatrial interval, was commonly induced in AVNRT cases (75%) but not in NV/NF-ORT cases (0%; p = 0.0005). Wenckebach VAB was common in NV/NF-ORTs (78%), but VAB patterns varied in AVNRTs. The His-His interval transiently prolonged in the following beat after the VAB in most AVNRTs but rarely did in NV/NF-ORTs (79% vs. 22%; p = 0.01). NV/NF-ORT was diagnosed by His-refractory premature ventricular contractions (n = 5) and the findings during right ventricular overdrive pacing showing an uncorrected/corrected post-pacing interval (PPI)-tachycardia cycle length (TCL) ≤115/110 ms (n = 5/5), orthodromic His capture (n = 6), and V-V-A (ventricle-ventricle-atrial response) response (n = 3). A single form of induced SVT (positive predictive value [PPV]: 69%; negative predictive value [NPV]: 100%), Wenckebach VAB (PPV: 70%; NPV: 87%), stable His-His interval despite VAB (PPV: 70%; NPV: 85%), orthodromic His capture (PPV: 100%; NPV: 97%), and V-V-A response (PPV: 100%; NPV: 95%) characterized NV/NF-ORT, and a PPI-TCL of ≤125 ms (PPV: 100%; NPV: 100%) characterized NV-ORT. CONCLUSIONS: Induction of a single SVT form, Wenckebach VAB, stable His-His interval despite VAB, orthodromic His capture, and V-V-A response appeared to discriminate NV/NF-ORT from AVNRT, with a PPI-TCL of ≤125 ms discriminating NV-ORT from NF-ORT and AVNRT.
OBJECTIVES: This study sought to assess the performance of current diagnostic criteria and identify additional electrophysiological features differentiating orthodromic reciprocating tachycardia (ORT) with a concealed nodoventricular/nodofascicular (NV/NF) pathway from atrioventricular nodal re-entrant tachycardia (AVNRT). BACKGROUND: Diagnosing sustained supraventricular tachycardia (SVT) despite the occurrence of ventriculoatrial block (VAB) is challenging. METHODS: We analyzed electrograms of 25 sustained SVTs (9 NV/NF-ORTs [n = 7/2] and 16 AVNRTs) with VAB and 91 AVNRTs without VAB (for reference). RESULTS: More than 1 SVT, each with a different ventriculoatrial interval, was commonly induced in AVNRT cases (75%) but not in NV/NF-ORT cases (0%; p = 0.0005). Wenckebach VAB was common in NV/NF-ORTs (78%), but VAB patterns varied in AVNRTs. The His-His interval transiently prolonged in the following beat after the VAB in most AVNRTs but rarely did in NV/NF-ORTs (79% vs. 22%; p = 0.01). NV/NF-ORT was diagnosed by His-refractory premature ventricular contractions (n = 5) and the findings during right ventricular overdrive pacing showing an uncorrected/corrected post-pacing interval (PPI)-tachycardia cycle length (TCL) ≤115/110 ms (n = 5/5), orthodromic His capture (n = 6), and V-V-A (ventricle-ventricle-atrial response) response (n = 3). A single form of induced SVT (positive predictive value [PPV]: 69%; negative predictive value [NPV]: 100%), Wenckebach VAB (PPV: 70%; NPV: 87%), stable His-His interval despite VAB (PPV: 70%; NPV: 85%), orthodromic His capture (PPV: 100%; NPV: 97%), and V-V-A response (PPV: 100%; NPV: 95%) characterized NV/NF-ORT, and a PPI-TCL of ≤125 ms (PPV: 100%; NPV: 100%) characterized NV-ORT. CONCLUSIONS: Induction of a single SVT form, Wenckebach VAB, stable His-His interval despite VAB, orthodromic His capture, and V-V-A response appeared to discriminate NV/NF-ORT from AVNRT, with a PPI-TCL of ≤125 ms discriminating NV-ORT from NF-ORT and AVNRT.