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Multicenter Study
. 2019 Sep;24(5):e12650.
doi: 10.1111/anec.12650. Epub 2019 Apr 16.

When and how does a single ventricular premature beat initiate and terminate supraventricular tachycardia?

Magno Cunha Guerra  1 , Yash Lokhandwala  2 , Rodulfo Oyarzun  3 , Aniruddha Vyas  4 , Frederico Soares Correa  5 , Fernando Eugenio Cruz Filho  6 , Hein J Wellens  7 , Eduardo Back Sternick  1   5
Affiliations
Multicenter Study

When and how does a single ventricular premature beat initiate and terminate supraventricular tachycardia?

Magno Cunha Guerra et al. Ann Noninvasive Electrocardiol. 2019 Sep.

Abstract

Background: The differential diagnosis of a supraventricular tachycardia (SVT) is accomplished using a number of pacing maneuvers. The incidence and mechanism of a single ventricular premature beat (VPB) on initiation and termination of tachycardia were evaluated during programmed electrical stimulation (PES) of the heart in patients with the two most common regular SVTs: atrioventricular re-entrant tachycardia (AVNRT) and orthodromic atrioventricular tachycardia (AVRT).

Methods: Three hundred and thirty-seven consecutive patients aged above 18 years with an inducible sustained AVNRT or AVRT were prospectively enrolled. Patients with more than one tachyarrhythmia mechanism were excluded. Two hundred and seventeen patients (64.4%) had typical slow/fast AVNRT and 120 (35.6%) had an orthodromic AVRT using a rapidly conducting accessory pathway for V-A conduction. In this cross-sectional study, we specifically report the analysis of tachycardia induction and termination by a single VPB.

Results: Tachycardia induction with a single VPB during sinus rhythm was seen in 7 of 120 AVRT and in only one of the 217 patients with AVNRT, (5.8% vs. 0.3%, p < 0.05). When a single VPB was delivered during basic ventricular pacing these values were 28% versus 4%, respectively, (p < 0.001). Termination of tachycardia by a single VPB was observed in nine (4.1%) patients with AVNRT and in 57 (47.5%) with AVRT (p < 0.001).

Conclusion: Initiation of SVT by a single VPB during sinus rhythm was uncommon and favored AVRT. Termination of SVT by a single VPB was commonly seen in AVRT but rarely in AVNRT. These findings can be of help when interpreting a noninvasive arrhythmia event recording.

Keywords: cardiac rhythm event recorders; electrophysiologic study; supraventricular tachycardia; tachycardia mechanisms.

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Conflict of interest statement

There is no conflict of interest to disclose.

Figures

Figure 1
Figure 1
Initiation of AVNRT by a single VPB during sinus rhythm. Five surface ECG's are shown, together with several intracardiac recordings, from the bundle of His, the coronary sinus (SC) and the apex of the right ventricle (VD). Paper speed 50 mm/s
Figure 2
Figure 2
Scatterplot showing single VPB termination in AVNRT and AVRT, in relation to tachycardia cycle length with a cutoff 350 ms. A single VPB could terminate only five AVNRT's when the tachycardia cycle length was below 350 ms
Figure 3
Figure 3
Upper panel‐termination of an AVNRT by a single right ventricular VPB. The VPB after 240 ms does not affect the timing of the next AVNRT QRS (400 + 480 = 2 × 440 ms), but the VPB after 230 ms invades the tachycardia circuit terminating the circulating AV nodal impulse. A 12‐lead ECG is shown with simultaneous recordings from the His bundle, coronary sinus, and right ventricle. Lower panel‐termination of an AVNRT after a single right ventricular VPB. The VPB, given after 220 ms, is retrogradely conducted to the atrium over the fast AV nodal pathway. The tachycardia terminates in the anterograde slow pathway. Paper speed 50 mm/s
Figure 4
Figure 4
A VPB given after 340 ms retrogradely invades the His bundle (marked by arrow), which was activated 10 ms earlier than during AVNRT, without changing AA timing. The narrow QRS after the VPB is the result of anterograde slowing in the slow AV nodal pathway (HH prolongs by 25 ms). As shown by the absence of retrograde atrial activation the AVNRT terminates by retrograde block in the fast AV nodal pathway. Paper speed 100 mm/s
Figure 5
Figure 5
Figure explaining why initiation and termination by a single VPB is more easy during orthodromic AVRT and unusual in AVNRT (see text)
See this image and copyright information in PMC

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