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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3849_Библиотеки_им_академика_М_И_Перельмана
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Apr 2021Jun 2021Aug 2021Oct 2021Dec 2021 Feb 2021 Apr 2022
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P. Patel et al.
Fig. 4.14 A rhythm strip showing intermittent failure to capture in the atrium
as seen by no P wave after a pacing spike
P = Program
I = Interrogate
_ = Remote
One or more
shocks/day
Treated VT/VF
episodes/day
V. rate during VT/VF
(bpm)
–VF
Non-sustained VT
episodes/day
AT/AF total hours/day
V. rate during AT /AF
(bpm)
max/day
↓
avg/day
% Pacing/day
–Atrial
–Ventricular
Avg V. rate (bpm)
–Day
–Night
Patient activity
hours/day
PPPI I_II
P
A
V
>5
4
3
2
1
0
>250
200
150
<100
>10
8
6
4
2
0
24
20
16
12
8
4
0
>200
150
100
<50
100
75
50
25
0
>120
100
80
60
<40
4
3
2
1
0
Apr 2021Jun 2021Aug 2021Oct 2021Dec 2021 Feb 2021 Apr 2022
Fig. 4.15 Overview of diagnostic data including arrhythmia burden, pacing
percentage and patient status
Apr 2021 Jun 2021 Aug 2021 Oct 2021 Dec 2021 Feb 2021 Apr 2022
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OptiVol 2.0 fluid index is an accumulation of the difference between the daily and reference impedance.
PPPI III
P
OptiVol 2.0 fluid index
_OptiVol
threshold
Thoracic impedance
(ohms)
–Daily
–Reference
Heart rate variability
(ms)
>200
160
120
80
40
Fluid
0
Apr 2021 Jun 2021 Aug 2021 Oct 2021 Dec 2021 Feb 2021 Apr 2022
>100
90
80
70
60
50
40
Apr 2021 Jun 2021 Aug 2021 Oct 2021 Dec 2021 Feb 2021 Apr 2022
>200
160
120
80
<40
75
Fig. 4.16 In OptiVol, as the intrathoracic uid increases, thoracic impedance
decreases
prole. Much data can be gleaned which can help titrate medications and guide appropriate therapy recommendations.
Heart failure diagnostic information can be assessed on certain
debrillators, since uid is a good conductor of electrical current.
OptiVol uid index, in Medtronic devices, measures intrathoracic
impedance (Fig.4.16). The impedance decreases as the amount of
uid in the lungs increases. Heart Logic Index (Fig. 4.17), in
Boston Scientic devices utilizes 5 sensors—heart sounds, thoracic impedance, respiration, heart rate and activity. Abbott
CorVue also measures intrathoracic impedance. These algorithms
are meant to be used in concert with a clinical assessment as tools
to help address heart failure status and impending heart failure
episodes.
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P. Patel et al.
Fig. 4.17 Heart Logic (Boston Scientic) notes 5 sensors (not all shown in
gure) and reports as an index. 16 and below is consistent with appropriate
volume status
Devices record arrhythmias, such as SVT, AT, VT, AFib, or
atrial flutter. These include a rhythm strip, time and date of
the event, duration, average ventricular response/heart rate.
Examination of the intracardiac electrograms can help with
diagnosis and aid in tailoring therapy (Figs.4.18, 4.19, 4.20).
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Fig. 4.18 Sustained VT, with successful ATP therapy avoiding the need for
ICD shock
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Fig. 4.19 Sustained rapid VT, resulting in ICD shock. Note more ventricular
than atrial signals consistent with VT
P. Patel et al.
Fig. 4.20 Atrial brillation with demand ventricular pacing
Conclusion
Device based therapy has a primary role in the eld of electrophysiology. From the extensive monitoring provided by an
implantable cardiac monitor to the lifesaving capabilities of an
implantable cardiac debrillator these devices have helped millions of patients worldwide. Having a fundamental knowledge of
the technology available will allow the treating provider to maximize the offerings currently available and take advantage of future
innovations in this exciting eld.
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management of patients with bradycardia and cardiac conduction delay.
Circulation. 2019;140:e382–482.
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3. Bisagnani A, et al. Implantable loop recorder in clinical practice. J
Arrhythm. 2019;35:25–32.
4. Hayase J, etal. Debrillation testing during ICD implantation—should
we or should we not? JAFIB. 2017;9:5.
5. Wilkoff B, etal. 2015 HRS/EHRA/APHRS/SOLAECE expert consensus
statement on optimal implantable cardioverter-debrillator programming
and testing. Europace. 2016;18:159–83.
6. Moss AJ, etal. Cardiac-resynchronization therapy for the prevention of
heart-failure events. N Engl J Med. 2009;361(14):1329–38.
7. Kaya E, etal. Subcutaneous ICD: current standards and future perspective. IJC Heart Vasc. 2019;24:100409.
8. Madhavan M, etal. Advances and future directions in cardiac pacemakers. J Am Coll Cardiol. 2017;69:211–35.
9. Bencardino G, etal. Leadless pacemaker technology: clinical evidence of
new paradigm of pacing. Rev Cardiovasc Med. 2022;23(2):043.
10. Naqvi TZ, Chao CJ.Adverse effects of right ventricular pacing on cardiac
function: prevalence, prevention and treatment with physiologic pacing.
Trends Cardiovasc Med. 2021;
11. Wilkoff BL, etal. Dual-chamber pacing or ventricular backup pacing in
patients with an implantable debrillator: the dual chamber and VVI
implantable debrillator (DAVID) trial. JAMA. 2002;288(24):3115–23.
12. Vijayaraman P, et al. His bundle pacing. J Am Coll Cardiol.
2018;72(8):927–47.
13. Deshmukh P, etal. Permanent, direct His-bundle pacing: a novel approach
to cardiac pacing in patients with normal His-Purkinje activation.
Circulation. 2000;101(8):869–77.
14. Sharma PS, etal. Permanent his-bundle pacing as an alternative to biventricular pacing for cardiac resynchronization therapy: a multicenter experience. Heart Rhythm. 2018;15(3):413–20.
15. Arnold AD, et al. His resynchronization versus biventricular pacing in
patients with heart failure and left bundle branch block. J Am Coll
Cardiol. 2018;72(24):3112–22.
16. Zhang S, Zhou X, Gold MR.Left bundle branch pacing: JACC review
topic of the week. J Am Coll Cardiol. 2019;74(24):3039–49.
17. Ponnusamy SS, etal. Left bundle branch pacing: a comprehensive review.
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18. Wu S, Sharma PS, Huang W.Novel left ventricular cardiac synchronization: left ventricular septal pacing or left bundle branch pacing? Europace.
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19. Arnold AD, Whinnett ZI, Vijayaraman P.His-Purkinje conduction system
pacing: state of the art in 2020. Arrhythm Electrophysiol Rev.
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21. Vijayaraman P, et al. Clinical outcomes of conduction system pacing
compared to biventricular pacing in patients requiring cardiac resynchronization therapy. Heart Rhythm. 2022;19(8):1263–71.
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management, part 1 of 2. J Am Coll Cardiol. 2017;69:189–210.
P. Patel et al.
Diagnosis andTreatment
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ofSupraventricular
Tachycardias
SpencerRosero andTravisPrinzi
Abstract
Supraventricular tachycardias are a group of arrhythmias that
include atrio-ventricular nodal tachycardias (AVNRT), atrial
tachycardia, and atrio-ventricular reentry tachycardias (AVRT)
including Wolff-Parkinson-White Syndrome. Each of these
arrhythmias, while originating in the upper chambers of the
heart, involve various diagnostic maneuvers to determine their
exact origin and treatment. Some will require simple pacing
maneuvers to determine diagnosis, while others will involve
complex, high density mapping from advanced mapping systems and algorithms in order to precisely treat the arrhythmia’s
origin. Careful attention must be given to differential diagnostic maneuvers and to 3D map interpretation.
5
Keywords
Supraventricular tachycardia · Atrial tachycardia ·
Atrioventricular nodal reentrant tachycardia · Atrio-ventricular
tachycardia · Accessory pathways · Atrial tachycardia · Ablation
3D mapping · Pacing maneuvers
S. Rosero (*) · T. Prinzi
University of Rochester Medical Center, Rochester, NY, USA
e-mail: Spencer_Rosero@urmc.Rochester.edu
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
D. T. Huang et al. (eds.), Cardiac Electrophysiology in Clinical
Practice, In Clinical Practice,
https://doi.org/10.1007/978-3-031-41479-4_5
81
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S. Rosero and T. Prinzi
The purpose of this chapter is to provide a basic overview of the
mechanisms, management and practical considerations in the
electrophysiology laboratory.
Introduction
Supraventricular tachycardias are a group of arrhythmias that
include atrio-ventricular nodal tachycardias (AVNRT), atrial tachycardia, and atrio-ventricular reentry tachycardias (AVRT) including
Wolff-Parkinson-White Syndrome. The purpose of this chapter is to
provide a basic overview of the mechanisms, management and
practical considerations in the electrophysiology laboratory.
Atrioventricular Nodal Reentry
The most common type of SVT is atrioventricular nodal reentry
(AVNRT), accounting for the majority of diagnosed SVT in patients
under 50years, with a higher prevalence in women compared to
men. Quality of life has also been shown to be affected in various
populations [1, 2]. Clinical ECG demonstrates a short RP, narrow
complex tachycardia with evidence of retrograde conduction seen
as a pseudo S wave with a superior axis P waves (Fig.5.1).
Fig. 5.1 ECG of AVNRT. Notice retrograde P waves forming a pseudo S
pattern in several leads
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This short RP tachycardia involves a reentry mechanism within
the AV node and is based on the concept of dual AV nodal
physiology . The reentrant circuit is dependent on the presence of
at least two functional pathways with differing refractoriness and
conduction properties. Typical AVNRT, the most frequent form,
uses the slow pathway for antegrade conduction, and the fast pathway for retrograde limb to complete the circuit and is classically
triggered by an APC blocking in the fast pathway but conducting
slowly down the slow pathway allowing retrograde recovery of
the fast pathway to produce a closed loop (Fig.5.2) [3, 4].
The two pathways do not seem separable by pathologic examination but the characteristics are encoded within the cellular distribution, and the characteristics for electrophysiology properties
are functional [4–6]. The differentiation of function within the AV
node was originally discovered from analyzing atrial pacing data
using progressively shorter atrial extrastimuli cycle lengths (A1A2) and measuring the A-H conduction times, during which it
was noted that a large “jump” of at least 50msec occurred at a
specic 10ms decrement in A1-A2 cycle length after which the
resumption of gradual normal decremental conduction would
continue on a different slope (Fig.5.3). This reproducible nding
conrmed the functional presence of dual pathway physiology
Fig. 5.2 Diagram of dual pathway physiology within the AV node and initiation via an APC
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