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Supraventricular arrhythmias

Hauda el rasyid
Indonesian Heart rhytm society,

Divisi aritmia
Bagian kardiologi dan kedokteran vaskular
FK UNAND/RSUP DR. M. Djamil Padang
AVNRT, AV nodal reentrant tachycardia

AVRT, Atrioventricular reciprocating tachycardia

AT, atrial tachycardia

JT, junctional tachycardia

Anatomy & Physiology
SA node
1 mm subendocardial near RSPV
AV node
Decremental conduction properties
Accessory pathways
No decremental conduction
AV conduction 10-20 ms
AV nodal reentrant tachycardia,
most common cause of SVT
more common in women than in men
all age groups
at least two pathways of tissue in their AV
node that allows for an abnormal electrical
circuit to perpetuate within their AV node.
Most common cause of a regular narrow complex
Involves a slow and a fast pathway in the region of
the AV node
Turn around point appears above the bundle of His
160-190 bpm but may exceed 200 bpm
Slow-fast form accounts for 90% of AVNRT
Fast-slow or slow-slow AVNRT accounts for 10%
Pseudo r in V1, pseudo S wave in 2,3,avf, and p wave
absence help distinguish AVNRT from AVRT and atrial
Initiation and termination by APDs, VPDs or atrial
pacing during AVW
Dual AVN physiology
Initiation depends on critical A-H delay
Concentric retrograde atrial activation(V-A -42 to 70
Retrograde P wave within QRS with distortion of
terminal portion of the QRS
Atrium, His bundle and ventricle not required , vagal
maneuvers slow and then terminate SVT
palpitation, lightheadedness, dizziness,
shortness of breath, reduced exercise capacity,
weakness, fatigue, chest discomfort, and
sweating episodes.
-due to loss of atrioventricular
synchrony (when then atria and ventricles no
longer contract in a tightly-coupled
progression) or the development of rapid
and/or irregular ventricular rates
Symptoms last as long as the episode of SVT lasts.
This may be seconds, minutes, hours, or rarely longer.

Symptoms Include the following:

Your pulse rate becomes 150 200 beats per minute.
Palpitations (Feeling your heart beat)
Dizziness, or Feeling Light Headed
You may become breathless
If you have angina, then an angina pain may be triggered by an
episode of SVT
You may have no symptoms, You may only be aware that your
heart is beating fast. Nervousness
AVNRT Treatment
Low threshold for catheter ablation given long term
success rate > 90% and low risk of complications
AV nodal blocking agents (diagnosis/treatment)
Anti-arrhythmics (third choice)
Atrioventricular reciprocating
an accessory, or extra, connection exists
between the top atria and the
bottom ventricles present
less than 1% of the general population
AVRT Treatment
Low threshold for catheter ablation given long term
success rate > 90% and low risk of complications
Posteroseptal pathways have less success rates
L sided
AV nodal blocking agents (diagnosis/treatment)
BB orCCB in conjunction with Flecainide or Propafenone
Focal Atrial Tachycardia
Incessant or paroxysmal atrial rhythms 120-
250 bpm
Demographic profile similar to reentrant AT,
but less likely to have cardiac surgery
Typically 1:1 conduction
P wave morphology different from sinus
Typically terminate or transiently suppress
with adenosine
Centrifugal activation
Cannot be entrained
Junctional Tachycardia
Nonparoxysmal Junctional Tachycardia
Junctional Ectopic Tachycardia
Congenital Automatic Junctional Tachycardia
Atrial flutter
Irregularly irregular rhythms
ATach with variable conduction
Radiofrequency Catheter Ablation
Who should be referred?
What arryhthmias should be referred for
What are the success rates?
What are the risks of ablation?
Who should be referred?
Symptomatic patients
AVNRT (>90% succes rates)
WPW and symptomatic AVRT (CCB ; BB and Dig not
appropriate as sole therapy) (>90%)
AFib (40-70%)
High risk for sudden death
AFib with WPW and cycle length <250 ms
Not amenable to catheter ablation
Reversible causes (thryotoxicosis; PE; post-op)
Question 1
A 35-year old woman with unrepaired Ebstein's anomaly is evaluated in
the emergency department for recurrent tachycardia episodes. Several
episodes occur while she is being evaluated. She notes that she feels
somewhat lightheaded.
The patient's blood pressure is 110/60 mm Hg. She is acyanotic and
afebrile. Cardiac examination demonstrates a brief systolic murmur along
the lower left sternal border, which increases with inspiration. The jugular
venous pressure is elevated.
The electrocardiogram shows a short PR interval, an abnormal initial
portion of the QRS complex, and right bundle branch block. The
tachycardia is wide-complex and regular at a rate of 190/min.

What is the most appropriate acute treatment of choice?

A Adenosine
B Procainamide
C Digoxin
D Direct-current cardioversion
Question 2
A 26-year-old nurse is evaluated in the emergency department after an
episode of syncope. While working in the intensive care unit, she
developed tachycardia and then lost consciousness. She admits to having
a stressful day and having had more caffeine than normal. She has had
brief episodes of tachypalpitations in the past but no prior syncope.
Physical examination is unremarkable and the patient is in sinus rhythm.
The chest radiograph is unremarkable. The electrocardiogram initially
demonstrates sinus rhythm and is unremarkable. Ten minutes later, the
patient develops an episode of brief tachycardia. Shortly after the
tachycardia episode, a repeat electrocardiogram is performed and is
shown (Figure 122).

What is the most likely diagnosis in this patient?

A Atrioventricular nodal reentrant tachycardia
B Accelerated idioventricular tachycardia
C Atrioventricular reentrant tachycardia
D Multifocal atrial tachycardia