Catheter Ablation: Insights on AVNRT and AVRT Diagnoses - Cardiology

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Cardiac catheterization


1.
Is it possible for AV nodal reentrant tachycardia (AVNRT) and atrioventricular reentrant tachycardia (AVRT) to coexist, given that the diagnoses from the two catheterizations were different?
2.
Although the ablation was empirical, does this indicate that the parahisian accessory pathway indeed exhibited abnormal electrical activity?
3.
In the electrocardiogram (ECG) records, a delta wave was detected during the first ablation but not during the second.
However, one of the characteristics of AVRT is the presence of a delta wave.
Why was AVNRT diagnosed during the first procedure and AVRT during the second?
4.
It was observed that the ECG during the PSVT episodes prior to the first ablation was completely different from that prior to the second ablation.
Additionally, the heart rate during the second episode (up to 220 bpm) was significantly faster than during the first (up to 180 bpm).
What could explain this difference?
5.
The first ablation mentioned a VAAV pattern after entrainment, which was considered suspicious.
Could this be a potential concern for the future?

Qiu, 20~29 year old female. Ask Date: 2024/02/06

Dr. Huang Yinghe reply Cardiology


1.
It is indeed possible for a patient to have two or more types of arrhythmias simultaneously.

2.
According to the information, the empiric ablation site is the slow conduction pathway.
Since AV nodal reentrant tachycardia (AVNRT) accounts for over 70% of the causes of paroxysmal supraventricular tachycardia (PSVT), if the patient has a slow conduction pathway and clinically confirmed PSVT, empiric ablation of the slow pathway is consistent with medical standards.
Based on the surgical details, during the first procedure, the physician performed entrainment and Parahisian pacing to rule out a parahisian accessory pathway.

3.
Most atrioventricular reentrant tachycardias (AVRT) are orthodromic, and it is normal not to see a delta wave during an episode of PSVT.

4.
The heart rate is related to the patient's sympathetic nervous system activity at the time of the episode, whether medications are used, and whether there is associated bundle branch block; thus, two episodes may not necessarily involve the same arrhythmia.

5.
In the catheterization lab, due to the nature of artificial electrical stimulation and the frequent need for pharmacological induction of episodes, non-clinical arrhythmias may often be triggered.
If such arrhythmias have not been clinically confirmed, it may be reasonable to consider follow-up observation.

Reply Date: 2024/02/06

More Info


Understanding catheter ablation, particularly in the context of arrhythmias such as Atrioventricular Nodal Reentrant Tachycardia (AVNRT) and Atrioventricular Reentrant Tachycardia (AVRT), can be complex. Your experiences with catheter ablation procedures and the varying diagnoses raise several important questions about the nature of these arrhythmias and their management.

1. Can AVNRT and AVRT coexist?
Yes, it is possible for AVNRT and AVRT to coexist in the same patient. Both conditions involve abnormal electrical pathways in the heart, but they arise from different mechanisms. AVNRT typically involves a reentrant circuit within or around the AV node, while AVRT involves an accessory pathway that connects the atria and ventricles outside the normal conduction system. In some cases, patients may have multiple arrhythmogenic pathways, leading to different diagnoses at different times.

2. Does empirical ablation indicate abnormal electrical activity in the parahisian accessory pathway?
Empirical ablation refers to a procedure where the physician ablates a suspected pathway based on the clinical presentation and electrophysiological findings, even if the pathway is not definitively identified during the procedure. If the ablation was performed in the area of the parahisian region and resulted in the cessation of arrhythmias, it suggests that there was indeed abnormal electrical activity in that area, even if it was not conclusively demonstrated during the procedure.

3. Why was there a delta wave in the first procedure but not in the second?
The presence of a delta wave is characteristic of Wolff-Parkinson-White (WPW) syndrome, which is associated with AVRT due to an accessory pathway. The absence of a delta wave in the second procedure could indicate that the accessory pathway was not manifesting during that specific episode of tachycardia or that the pathway characteristics changed. The diagnosis of AVNRT in the first procedure may have been based on the specific electrophysiological findings at that time, while the second procedure confirmed the presence of an accessory pathway leading to AVRT.

4. Why were the ECG recordings different between the two procedures?
Variability in heart rate and ECG findings can occur due to several factors, including changes in autonomic tone, the presence of different arrhythmogenic triggers, or even the development of new pathways over time. The faster heart rate observed in the second procedure could be due to increased sympathetic stimulation or a different mechanism of tachycardia. Each episode of PSVT can have distinct characteristics based on the underlying mechanisms at play during that specific event.

5. Is the VAAV pattern after entrainment a future concern?
The VAAV pattern observed after entrainment during the first procedure may indicate the presence of an accessory pathway that could potentially lead to future arrhythmias. While it does not guarantee that arrhythmias will recur, it suggests that there may be an underlying substrate for reentrant tachycardia. Continuous monitoring and follow-up with your electrophysiologist are essential to assess for any recurrence of symptoms or arrhythmias.

In conclusion, your experiences highlight the complexity of diagnosing and managing arrhythmias like AVNRT and AVRT. It is crucial to maintain open communication with your healthcare provider, who can interpret these findings in the context of your overall clinical picture and guide you in managing your condition effectively. Regular follow-up and monitoring are essential to ensure that any potential issues are addressed promptly.

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