Calvo David, Ávila Pablo, García-Fernández F Javier, Pachón Marta, Bravo Loreto, Eidelman Gabriel, Hernández Jesús, Miracle Ángel L, Rubín José, Pérez Diego, Arenal Ángel, Atienza Felipe, Jimenez-Candil Javier, Arias Miguel Ángel, Datino Tomás, Martínez-Camblor Pablo, Gonzalez-Torrecilla Esteban, Almendral Jesús
From the Cardiology Department, Arrhythmia Unit (D.C., J.R., D.P.), and Department of Statistics (P.M.-C.), Hospital Universitario Central de Asturias, Oviedo, Spain; Cardiology Department, Arrhythmia Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain (P.Á., L.B., G.E., Á.A., F.A., T.D., E.G.-T.); Cardiology Department, Arrhythmia Unit, Hospital Universitario de Burgos, Burgos, Spain (F.J.G.-F.); Cardiology Department, Arrhythmia Unit, Hospital Virgen de la Salud, Toledo, Spain (M.P., M.A.A.); Cardiology Department, Arrhythmia Unit, Hospital Universitario de Salamanca, Salamanca, Spain (J.H., J.J.-C.); and Cardiology Department, Hospital Universitario Rey Juan Carlos (Á.L.M.), and Cardiology Department, Arrhythmia Unit, Grupo Hospital Madrid (J.A.), Madrid, Spain.
Circ Arrhythm Electrophysiol. 2015 Oct;8(5):1201-9. doi: 10.1161/CIRCEP.115.002949. Epub 2015 Sep 2.
Differential diagnosis between tachycardia mediated by septal accessory pathways (AP) and atypical atrioventricular nodal reentry can be challenging. We hypothesized that an immediate versus delayed pace-related advancement of the atrial electrogram, once the local septal parahisian ventricular electrogram (SVE) has been advanced, may help in this diagnosis.
We focused on differential timing between SVE and atrial signals at the initiation of continuous right ventricular apical pacing during tachycardia. SVE advancement preceding atrial reset was defined as SVE advanced by the paced wave fronts while atrial signal continued at the tachycardia cycle. We analyzed 51 atypical atrioventricular nodal reentry (45% posterior type) and 80 AP tachycardias (anteroseptal [10], parahisian [18], midseptal [12], and posteroseptal [40]). SVE advancement preceding atrial reset was observed in 98% of atrioventricular nodal reentries during 4±1.1 cycles; this phenomena was observed in 6 (8%) of the atrioventricular reentrant tachycardia mediated by septal AP (P<0.001; sensitivity 98%; specificity 93%; positive predictive value 90%; negative predictive value 99%) and lasted 1 single cycle (P<0.001). Right posteroseptal AP tachycardias were distinctly characterized by atrial reset preceding SVE advancement (with ventricular fusion; specificity 100%; positive predictive value 100%). In 11 cases, it was impossible to achieve sustain entrainment. In all of them, the differential responses at the entrainment attempt allowed for appropriate diagnosis.
The differential response of the SVE and the atrial electrogram at the initiation of continuous right ventricular apical pacing during tachycardia effectively distinguishes between atypical atrioventricular nodal reentry and atrioventricular reentrant tachycardia mediated by septal APs.
鉴别由间隔旁道（AP）介导的心动过速与不典型房室结折返可能具有挑战性。我们推测，一旦局部间隔希氏束旁心室电图（SVE）提前，心房电图的即刻与延迟起搏相关提前可能有助于这一诊断。
我们关注心动过速期间连续右心室心尖起搏起始时SVE与心房信号之间的差异时间。SVE提前于心房重置被定义为起搏波前使SVE提前，而心房信号在心动过速周期持续。我们分析了51例不典型房室结折返（45%为后位型）和80例AP心动过速（前间隔[10例]、希氏束旁[18例]、中间隔[12例]和后间隔[40例]）。在4±1.1个心动周期中，98%的房室结折返观察到SVE提前于心房重置；在由间隔AP介导的房室折返性心动过速中，6例（8%）观察到这种现象（P<0.001；敏感性98%；特异性93%；阳性预测值90%；阴性预测值99%），且持续1个心动周期（P<0.001）。右后间隔AP心动过速的明显特征是心房重置先于SVE提前（伴有心室融合；特异性100%；阳性预测值100%）。在11例中，无法实现持续夺获。在所有这些病例中，夺获尝试时的差异反应有助于做出正确诊断。
心动过速期间连续右心室心尖起搏起始时SVE与心房电图的差异反应可有效区分不典型房室结折返与由间隔AP介导的房室折返性心动过速。
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