ClinicalGeneralDiagnostic utility of early premature ventricular complexes in differentiating atrioventricular reentrant and atrioventricular nodal reentrant tachycardias
Introduction
A His-refractory premature ventricular complex (HrPVC) perturbing a supraventricular tachycardia (SVT) establishes the presence of an accessory pathway (AP). Earlier premature ventricular complexes (ErPVCs) are considered nondiagnostic because they may perturb atrioventricular nodal reentrant tachycardia (AVNRT) or atrioventricular tachycardia (AVRT). Because of a minimum retrograde conduction time from ventricle to the atrioventricular (AV) node, we hypothesized that a premature ventricular complex (PVC) will always show a difference >35 ms in its advancement of the next atrial activation during AVNRT. During AVRT, a PVC delivered close to the circuit can result in greater advancement of the next atrial activation due to retrograde conduction via an AP. Thus, if an early PVC (H1S2) advances the subsequent atrial activation (A1-A2) more than this minimum differential (A1A2 ≤ H1S2+35 ms), the presence of an AP is established (Figure 1).
Section snippets
Study population
Patients presenting to the St. Vincent Hospital (Indianapolis, IN) electrophysiology laboratory for ablation of SVT between November 2017 and March 2022 were retrospectively included. The hypothesis was tested in patients with sustained SVT suggestive of AVNRT or orthodromic AVRT during electrophysiological study (EPS). Patients with atrial tachycardias, SVT with cycle length variations, nonsustained tachycardias, and SVTs in which early PVCs could not be delivered due to tachycardia
Results
Among a total of 65 patients, 43 had AVNRT and 22 had AVRT. Mean patient age was 47 ± 21 years, and 57% were female.
Discussion
The major finding of this study is the diagnostic utility of early PVCs in identifying the presence of a retrogradely conducting AP to differentiate AVRT and AVNRT. As with HrPVC, a positive response establishes the presence but not the participation of an AP. We found that an AP response, A1A2 ≤ H1S2+35 ms, was 100% specific for AVRT. The high specificity is expected because the method uses the same physiological principles used in interpreting HrPVC responses. The application of the strictest
Conclusion
An AP response to early PVCs (A1A2 ≤ H1S2+35 ms) is 100% specific for the presence of an AP. The degree of atrial advancement may contain information to differentiate AVRT and AVNRT irrespective of the timing of the PVC.
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Funding Sources: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Disclosures: The authors have no conflicts of interest to disclose.