MANAGING SUPRAVENTRICULAR

TACHYARRYTHMIAS..Dr. Abhishek Das

Chairperson- Dr. B. P. Chatterjee, DM

To define..• Tachyarrythmia- sustained or non sustained forms of tachycardia

arising from myocardial foci or reentrant circuits.

• Tachycardia- rhythm producing ventricular rate >100 bpm

• Supraventricular tachyarrythmia- tachycardia in which the driving circuit or focus arises, at least in part, in tisuues above the level of ventricles.

• PSVT???

Non specific term ; encompass tachycardias with supraventricularQRS, regular R-R interval and no evidence of ventricular preexcitation.

SA node:S.T.

S.N.R.T

Atrium:APC

Atrial TachyMATAfib

AFlutter

AV Node:AVNRTAVRT

SVT encompasses..

Approach to management..

ECG approach..

Clinical evaluation in SVT

Symptoms-• Palpitations , Exertional fatigue/dyspnea ,Chest discomfort, Near-syncope (rarely

syncope)

HISTORY : MODE OF ONSET AND TERMINATION

• Triggers

• Abruptness of onset and termination - Common in AVRT and AVNRT

• Frequency of episodes-- Incessant is often AT

• Ability to stop symptoms- Common in AVRT and AVNRT

Major SVT types

Mechanism of AVNRT

Mechanism of AVRT..

CASE 1 : 32 yrs F with palpitations , vitals

stable

AV Nodal Reentrant Tachycardia(AVNRT)

CASE 1: how to treat??

• ACUTE ATTACK Rest, Reassurance,Sedation

VAGAL Manoeuvre ( Valsalva,CSM, Muller’s, ice water over face)

ADENOSINE- terminates 90% cases

Dose: 6-12 mg rapid intravenous

VERAPAMIL or DILTIAZEM rapid iv (if above manuevers fail)

Beta Blockers

CARDIOVERSION ??

DC shock synchronised, 10-50 Jules, in presence of hemodynamic instability, rarely needed

Can precipitate Vfib in case of Digitalis toxicity

Assess the need

DRUGS – long acting CCBs or long acting Beta Blockers

ABLATION –

• 95% long term cure

• Complete heart block<1%

• Recurrent, symptomatic, sustained AVNRT

• Drugs C/I, intolerant or do not want drugs

• Slow pathway ablation is commonly done, fast pathway preserved.

SECONDARY PROPHYLAXIS

Ventricular Pre excitation

Short PR

Delta Wave

WPW= PR<0.12s + DELTA + RAPID REGULAR TACHYARRYTHMIA

38 year old truck driver undergone a routine ecg for pre op.. CSOM operation

ORTHODROMIC

ANTIDROMIC

AF with ventricular preexcitation

• ~50% patients with an AP predisposed to AF

• Results from rapid antegrade conduction atria to ventricles over AP

• Rapid ventricular rates– haemodynamiccompromise– may ppt VF

• QRS pattern bizarre and beat to beat variability

Concealed AP s:

~50% of all Aps

No antegrade conduction, only retrograde

Manifest only during tachycardia

Orthodromic AVRT– only

Not at risk of RVR to Afib.

PJRT:

Slow retrograde conduction over AP

Long RP

“incessant” tachycardia

Tachycardia induced LV cardiomyopathy

Accessory pathway mediated

tachycardia- management

• Acute management- Vagal manuevers, ADENOSINE, IV CCB or BB

• Manifest preexcitation and AF—

Hemodynamic compromise- DC CARDIOVERSION

Non life threatening situation-

-----IV procainamide 15mg/kg over 20-30 mins to slow ventricular response.

Ibutilide

CAUTIOUS about using Digoxin or Verapamil

AVRT management cont….

• Chronic Rx- oral BB or CCB( verapamil/ditiazem)

--to prevent recurrences

• AF with RVR or recurrences of SVT on AVN blocking drugs

---- strongly consider CLASS 1A or 1C antiarryhmics( quinidine, flecainide, propafenone)

• ABLATION---- when????

Recurrent symptomatic SVT episodes

Incessant SVT

H.R>200bpm

Managing AVRT..• Accessory pathway ablation: Curative therapy for WPW and concealed accessory

pathways

By pass tract sites-

1. Left laterally, between LA & LV free walls (~50%)2. Posteriorly, between the atrial & ventricular septa

(~30%)3. Right laterally or anteriorly, between RA & RV free

walls (~20%)

Recurrence rate of AVRT post ablation <5-10%

AV Junctional Tachycardia• Enhanced normal automaticity, abnormal

automaticity or triggered activity

• Retrograde atrial conduction±

• P dissociated or intermittent conduction

• Sinus activity dissociated or intermittent captures• Digoxin toxicity may predispose

• Rate- 50-100 bpm---accelerated junctional rhythm

• Treatment- stop digoxin, Fab, BBs, anti arryths

Routine preop ECG of a 60y M ..Atrial Premature complexes

•P occurring before anticipated sinus beat•Different p contour•QRS- RBBB or LBBB may be seen•Sum of pre- and post- APC RR< 2 sinus ppinterval•Increase with age and structural hrt ds•Mostly DONOT NEED INTERVENTION

ATRIAL TACHYCARDIA

Inverted p

•Atrial rate-150-200bpm•Different p wave contour•Long RP, Short PR(RP>PR)•Short frequent bursts withspontaneous termination•May be a/w 2:1 or 3:2 AVblock•Iso electric intervalsbetween p waves•+ve or biphasic p in V1- LA•-ve p in V1 – RA focus

AT significant???• A/w Structural heart disease(CAD±MI, HF etc)

• DIGITALIS toxicity

• Incessant AT- risk of tachycardia induced CMP

• CSM/Adenosine– increases AV block, slowing ventricular rate without termination.

• Management-1. STOP DIGOXIN2. BB/CCB3. If fails– 1A,1C,34. ABLATION

ATRIAL TACH Ablation

• Common ectopic Atrial Tachycardia sites-

1. Crista terminalis2. Valvular annuli3. Pulmonary vein

ostia4. Coronary sinus

ostia• Recurrence rate of

AT post ablation <10%

CASE: A 57y M smoker, COPD for last 10 yrs

MULTIFOCAL ATRIAL TACHYCARDIA(MAT)

Multifocal atrial tchycardiaAtrial rhythm- at least 3 distinct p wave

3 different PR intervalsAtrial rates-100-150 /min

Presence of isoelectric baselineA/w chronic obstructive or restrictive lung ds

Treat underlying diseaseCCB, flecainide, propafenone- some role

Atrial flutter with 2:1 conduction

ATRIAL FLUTTER•Atrial rate- 250-300/min•Ventricular rate~150 bpm

•Regular or Irregular•Saw-toothed flutter waves

•Evidence of continual electrical activity•TYPICAL VS ATYPICAL

•Mechanism – Macroreentry•Structural heart disease, toxic- metabolic substrates

Afl- mechanism & ECG correlation….

Typical AflAtypical Afl

Managing atrial flutter..

ACUTE :: CARDIOVERSION (DCC Vs Pharma)

LONG TERM----

1. Anticoagulation (similar as Afib)

2. Control rate (CCB,Dig,BB)

3. Anti-arrythmics– CAUTIOUS about 1C and 3

4. Identify and treat underlying pathology.

5. ABLATION

Atrial Fibrillation

‘f’ waves

•Affects 2 to 4% of population

•Increases to 5 to 10 % of patients over 80

•Associated with 2-fold increased risk of death

•Risk of thromboembolism is approximately 5% per

year but may be as high as 20% in high risk groups not

anticoagulated

Types of Afib….

Management algorithm of Afib

THROMBOPROPHYLAXIS IN AF

LONG TERM Management--- RATE or RHYTHM ?

• AFFIRM trial- Rhythm vs Rate control strategy in AF patients…….result????NO SURVIVAL ADVANTAGE Rate control- less hospital admission and side

effects

INDIVIDUALISED approach

“Pill in the Pocket” approach

If only rate control,,, strict or lenient?? Outcome was same,, lenient more achievable

CHOICE of Anti-arrythmics…

NON-PHARMA STRATEGIES…

PACING

CATHETER ABLATION

ABLATION OF AV NODE

SURGICAL APPROACHES

ABLATION IN AF..

• Challenging

• All problems cant be solved

• Higher recurrence(vs AVNRT,AVRT)

• Treat with at least 1 rhythm control drug before

• Symptomatic Afib, min. struc heart disease

• Huge LA dilation, persistent>4 yrs– less chance of success

• RFA used for electrical isolation of PV

• C/I– LA thrombus

80 year old female with sepsis..

IS THIS SINUS TACHYCARDIA??

Maximal sinus tachycardia

• 220- age= Maximal heart rate

i.e. 220-80= 140 bpm

UNLIKELY THIS IS JUST SINUS TACHYCARDIA

SUMMARY

• IDENTIFY SVT at a first glance

• DO NOT waste time over pinpoint diagnosis

• MANAGE emergently

• SEARCH for reversible causes

• RULE out structural heart diseases

• DISCUSS with patients about long term strategy

THANK YOU..