38 F. ECG recorded during palpitations
ECG
- Regular
- Narrow QRS tachycardia
- QRS alternans
- PR = RP
Incremental ventricular pacing
Single ventricular extrastimulus
Atrial incremental pacing
Atrial extrastimulus 600/320
Atrial extrastimulus 600/310
Atrial extrastimulus 600/300
Tachycardia
RV overdrive pacing
Early PVC
VOP with Isoprenaline
Spontaneous termination
Initiation of tachycardia
Adenosine bolus
What now?
Diagnosis of SVT with septal atrial activation and inability to overdrive A
- VA unlinking during rapid atrial pacing (1)
- Differential atrial pacing and VA delta (2)
- Simultaneous atrial and ventricular pacing (3)
- Kadish et al. The Response of Paroxysmal Supraventricular Tachycardia to Overdrive Atrial and Ventricular Pacing. JCE 1993; 4(3): 239-252
- Sarkozy et al. A novel pacing manoeuvre to diagnose atrial tachycardia. EP Europace 2008; 10(4): 459–466
- Saba et al. A novel manoeuvre for discerning supraventricular tachycardia mechanism. Europace 2011; 13(4): 562–565
Sensitivity and specificity
Knight et al. Diagnostic value of tachycardia features and pacing maneuvers during paroxysmal supraventricular tachycardia. JACC 2000; 36(2): 574-582
Simultaneous atrial and ventricular pacing
Saba et al. A novel manoeuvre for discerning supraventricular tachycardia mechanism. Europace 2011; 13(4): 562–565
Burst atrial pacing
Activation mapping of AT
- Earliest in His region
- Small His EGM at best site
- Options ?
RAO view
LAO view
Ablation catheter in NCC
Successful ablation
Parahisian AT
- Paroxysmal tachycardia
- Middle aged women
- Adenosine sensitive
- Safer and effective ablation from NCC
Anatomic and embryologic correlation
Bohora et al. Reappraisal and new observations on atrial tachycardia ablated from the non-coronary aortic sinus of Valsalva. Europace. 2018 ;20(1):124-133