Yoshimura et al. A-V-V-A response to single atrial premature depolarization in a narrow QRS tachycardia: What is the mechanism?

IF 2.2 Q2 CARDIAC & CARDIOVASCULAR SYSTEMS
Abhishek Goyal MD, DM
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引用次数: 0

Abstract

I read with great interest the case report by Yoshimura et al. entitled “A-V-V-A response to single atrial premature depolarization in a narrow QRS tachycardia: What is the mechanism?”.1 The authors have discussed a very interesting case and tried to differentiate atypical atrioventricular nodal re-entrant tachycardia (AVNRT) from junctional ectopic tachycardia (JET) based on the available literature.2 However, discussion seems insufficient to withdraw a definite conclusion.

Firstly, the authors discuss the responses to atrial premature depolarization (APD) delivered during tachycardia based on article published by Padanilam et al.2 Padanilam et al. described that when a APD is timed to His refractoriness, any perturbation of the subsequent His indicates that impulse travels via anterograde slow pathway conduction and confirms the diagnosis of AVNRT. Timing of APD is very critical, and perturbation of the next tachycardia beat is confirmatory for AVNRT only when the APD could not have influenced the immediate beat. This response seems to be applicable in slow fast type of AVNRT as majority of the patients had short ventricular to high right atrium(V-HRA) interval. V-HRA interval was 80 ms in 20 of the 26 cases of AVNRT group, and the interval ranged from 102 to 140 ms (mean 121 ms) in the remaining six patients. The V-HRA interval in JET group of patients ranged from 15 to 62 ms (mean 36 ms). Whereas current report describes a case of fast slow type of AVNRT. Hence, approach suggested by Padanilam is not applicable here.

Second argument is based on the fact that the interval between the His-bundle potential before and one beat after APD was significantly longer than that of two beats of tachycardia cycle length (300 + 375 ms > 320 ms × 2), a finding that is unlikely in JET. On the contrary, it is possible in JET. Enhanced automaticity is postulated as the mechanism of JET3; hence, APD can supress this automatic focus transiently, which can gradually accelerate to tachycardia cycle length (TCL). This is also evident in current case report where HH interval gradually increases (375 msec➔ 345 msec ➔320 msec) post-APD stimulus. This explains why the interval before and one beat after APD is not the exact multiple of TCL.

Although it appears to be AVNRT based on the two discrete discontinuities observed in the AH conduction curve during programmed atrial extrastimulation, manoeuvres described in this case report appear to be insufficient to conclusively establish the diagnosis of AVNRT. Other manoeuvres such as delta H-A interval (H-A interval pacing minus the H-A tachycardia) and atrial-His-His-atrial response during atrial overdrive pacing of tachycardia might have been helpful.4, 5

N/A.

Authors declare no conflict of interests for this article.

N/A.

N/A.

N/A.

N/A.

Yoshimura 等人. 窄 QRS 心动过速时单个心房过早除极的 A-V-V-A 反应:机制是什么?
我饶有兴趣地阅读了 Yoshimura 等人撰写的病例报告,题为 "窄 QRS 心动过速时单个心房过早除极的 A-V-V-A 反应机制是什么?1 作者讨论了一个非常有趣的病例,并试图根据现有文献将非典型房室结再电位心动过速(AVNRT)与交界异位心动过速(JET)区分开来。首先,作者根据 Padanilam 等人发表的文章2 讨论了心动过速时对心房过早除极(APD)的反应。Padanilam 等人指出,当 APD 的时间与 His 的折返性一致时,随后 His 的任何扰动都表明冲动通过前向慢通路传导,从而确诊为 AVNRT。APD 的定时非常关键,只有当 APD 不可能影响紧接着的搏动时,下一个心动过速搏动的扰动才可确诊为 AVNRT。由于大多数患者的心室至右心房(V-HRA)间期较短,因此这种反应似乎适用于慢快型房室传导阻滞。在 26 例 AVNRT 组患者中,20 例患者的 V-HRA 间期为 80 毫秒,其余 6 例患者的 V-HRA 间期在 102 至 140 毫秒之间(平均 121 毫秒)。JET 组患者的 V-HRA 间期为 15 至 62 毫秒(平均 36 毫秒)。而本报告描述的是一例快慢型 AVNRT。第二个论点基于以下事实:APD 之前和之后一搏的 His-bundle 电位间期明显长于两搏心动过速周期长度(300 + 375 ms > 320 ms × 2),这一发现在 JET 中不太可能。相反,这在 JET 中是可能的。据推测,自动性增强是 JET 的机制3;因此,APD 可短暂抑制自动聚焦,从而逐渐加速至心动过速周期长度(TCL)。这在目前的病例报告中也很明显,即在 APD 刺激后,HH 间期逐渐增加(375 毫秒➔ 345 毫秒➔320 毫秒)。虽然根据程序性心房外刺激时在 AH 传导曲线上观察到的两个离散的不连续性,这似乎是 AVNRT,但本病例报告中描述的操作似乎不足以最终确定 AVNRT 的诊断。其他操作方法,如δ H-A 间期(H-A 间期起搏减去 H-A 心动过速)和心房超速起搏时的心房-His-His-心房反应可能会有所帮助。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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来源期刊
Journal of Arrhythmia
Journal of Arrhythmia CARDIAC & CARDIOVASCULAR SYSTEMS-
CiteScore
2.90
自引率
10.00%
发文量
127
审稿时长
45 weeks
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