Atrioventricular reentrant tachycardia (AVRT) associated with an accessory pathway
- Luigi Di Biase, MD, PhD, FHRS, FACC
Luigi Di Biase, MD, PhD, FHRS, FACC
- Cardiologist, Electrophysiologist, Section Head Electrophysiology, Director of Arrhythmia Services, Professor of Medicine, Department of Medicine (Cardiology), Albert Einstein College of Medicine at Montefiore Hospital, New York
- Senior Researcher, Texas Cardiac Arrhythmia Institute at St. David's M
- Edward P Walsh, MD
Edward P Walsh, MD
- Chief, Cardiac Electrophysiology, Boston Children’s Hospital
- Professor of Pediatrics, Harvard Medical School
- Section Editors
- Samuel Lévy, MD
Samuel Lévy, MD
- Section Editor — Cardiac Arrhythmias
- Professor of Cardiology
- University of Marseille, France
- Bradley P Knight, MD, FACC
Bradley P Knight, MD, FACC
- Section Editor — Cardiac Arrhythmias
- Professor of Medicine
- Feinberg School of Medicine, Northwestern University
In 1930, Louis Wolff, Sir John Parkinson, and Paul Dudley White published a seminal article describing 11 patients who suffered from attacks of tachycardia associated with a sinus rhythm electrocardiographic (ECG) pattern of bundle branch block with a short PR interval . This was subsequently termed the Wolff-Parkinson-White (WPW) syndrome, although earlier isolated case reports describing similar findings had already been published. In 1943, the ECG features of preexcitation were correlated with anatomic evidence for the existence of anomalous bundles of conducting tissue that bypassed all or part of the normal atrioventricular (AV) conduction system (figure 1).
Atrioventricular reentrant (or reciprocating) tachycardia (AVRT) is a reentrant tachycardia with an anatomically defined circuit that consists of two distinct pathways, the normal AV conduction system and an AV accessory pathway, linked by common proximal (the atria) and distal (the ventricles) tissues. While other arrhythmias can utilize the accessory pathway for conduction from the anatomic site of tachycardia origin to other regions of the heart (eg, atrial fibrillation and atrial flutter) (figure 2), AVRT is a specific reentrant tachycardia in which the accessory pathway is necessary for initiation and maintenance of the tachycardia .
The different types of AVRT, along with their ECG findings, will be discussed here. The approach to treatment of arrhythmias associated with an accessory pathway is presented in detail separately. (See "Treatment of symptomatic arrhythmias associated with the Wolff-Parkinson-White syndrome".)
NORMAL AV CONDUCTION VERSUS ACCESSORY AV PATHWAY CONDUCTION
Normal atrioventricular (AV) conduction occurs through the AV node. However, in the presence of an accessory pathway, conduction from the atria to the ventricles may occur in a variety of ways (exclusively via the AV node, exclusively via the accessory pathway, or a combination of both). Normal and accessory AV conduction are discussed in detail elsewhere. (See "Epidemiology, clinical manifestations, and diagnosis of the Wolff-Parkinson-White syndrome", section on 'Normal AV conduction versus accessory AV pathway conduction'.)
TACHYCARDIAS REQUIRING AN AV ACCESSORY PATHWAY FOR INITIATION AND MAINTENANCE
AVRT is a reentrant tachycardia with an anatomically defined circuit that consists of two distinct pathways, the normal AV conduction system and an AV accessory pathway, linked by common proximal (the atria) and distal (the ventricles) tissues. If sufficient differences in conduction time and refractoriness exist between the normal conduction system and the accessory pathway, a properly timed premature impulse of atrial, junctional, or ventricular origin can initiate reentry. (See "Reentry and the development of cardiac arrhythmias".)
- Wolff L, Parkinson J, White PD. Bundle-branch block with short P-R interval in healthy young people prone to paroxysmal tachycardia. 1930. Ann Noninvasive Electrocardiol 2006; 11:340.
- Josephson ME. Preexcitation syndromes. In: Clinical Cardiac Electrophysiology, 4th, Lippincot Williams & Wilkins, Philadelphia 2008. p.339.
- Chugh A, Morady F. Atrioventricular reentry and variants. In: Cardiac electrophysiology from cell to bedside, 5th edition, Zipes DP, Jalife J. (Eds), Saunders/Elsevier, Philadelphia 2009. p.605-614.
- Akhtar M, Lehmann MH, Denker ST, et al. Electrophysiologic mechanisms of orthodromic tachycardia initiation during ventricular pacing in the Wolff-Parkinson-White syndrome. J Am Coll Cardiol 1987; 9:89.
- Cain ME, Luke RA, Lindsay BD. Diagnosis and localization of accessory pathways. Pacing Clin Electrophysiol 1992; 15:801.
- Green M, Heddle B, Dassen W, et al. Value of QRS alteration in determining the site of origin of narrow QRS supraventricular tachycardia. Circulation 1983; 68:368.
- Kay GN, Pressley JC, Packer DL, et al. Value of the 12-lead electrocardiogram in discriminating atrioventricular nodal reciprocating tachycardia from circus movement atrioventricular tachycardia utilizing a retrograde accessory pathway. Am J Cardiol 1987; 59:296.
- Tchou PJ, Lehmann MH, Dongas J, et al. Effect of sudden rate acceleration on the human His-Purkinje system: adaptation of refractoriness in a dampened oscillatory pattern. Circulation 1986; 73:920.
- Gallagher JJ, Sealy WC, Kasell J, Wallace AG. Multiple accessory pathways in patients with the pre-excitation syndrome. Circulation 1976; 54:571.
- Man KC, Brinkman K, Bogun F, et al. 2:1 atrioventricular block during atrioventricular node reentrant tachycardia. J Am Coll Cardiol 1996; 28:1770.
- Nelson SD, Kou WH, Annesley T, et al. Significance of ST segment depression during paroxysmal supraventricular tachycardia. J Am Coll Cardiol 1988; 12:383.
- Riva SI, Della Bella P, Fassini G, et al. Value of analysis of ST segment changes during tachycardia in determining type of narrow QRS complex tachycardia. J Am Coll Cardiol 1996; 27:1480.
- Scheinman MM, Wang YS, Van Hare GF, Lesh MD. Electrocardiographic and electrophysiologic characteristics of anterior, midseptal and right anterior free wall accessory pathways. J Am Coll Cardiol 1992; 20:1220.
- Brembilla-Perrot B, Pauriah M, Sellal JM, et al. Incidence and prognostic significance of spontaneous and inducible antidromic tachycardia. Europace 2013; 15:871.
- Ceresnak SR, Tanel RE, Pass RH, et al. Clinical and electrophysiologic characteristics of antidromic tachycardia in children with Wolff-Parkinson-White syndrome. Pacing Clin Electrophysiol 2012; 35:480.
- Zachariah JP, Walsh EP, Triedman JK, et al. Multiple accessory pathways in the young: the impact of structural heart disease. Am Heart J 2013; 165:87.
- Dorostkar PC, Silka MJ, Morady F, Dick M 2nd. Clinical course of persistent junctional reciprocating tachycardia. J Am Coll Cardiol 1999; 33:366.
- Aguinaga L, Primo J, Anguera I, et al. Long-term follow-up in patients with the permanent form of junctional reciprocating tachycardia treated with radiofrequency ablation. Pacing Clin Electrophysiol 1998; 21:2073.
- Guarnieri T, Sealy WC, Kasell JH, et al. The nonpharmacologic management of the permanent form of junctional reciprocating tachycardia. Circulation 1984; 69:269.
- Ticho BS, Saul JP, Hulse JE, et al. Variable location of accessory pathways associated with the permanent form of junctional reciprocating tachycardia and confirmation with radiofrequency ablation. Am J Cardiol 1992; 70:1559.
- Packer DL, Bardy GH, Worley SJ, et al. Tachycardia-induced cardiomyopathy: a reversible form of left ventricular dysfunction. Am J Cardiol 1986; 57:563.
- Brugada P, Vanagt EJ, Bar FW, Wellens HJ. Incessant reciprocating atrioventricular tachycardia. Factors playing a role in the mechanism of the arrhythmia. Pacing Clin Electrophysiol 1980; 3:670.
- Critelli G, Gallagher JJ, Monda V, et al. Anatomic and electrophysiologic substrate of the permanent form of junctional reciprocating tachycardia. J Am Coll Cardiol 1984; 4:601.
- Okumura K, Henthorn RW, Epstein AE, et al. "Incessant" atrioventricular (AV) reciprocating tachycardia utilizing left lateral AV bypass pathway with a long retrograde conduction time. Pacing Clin Electrophysiol 1986; 9:332.
- NORMAL AV CONDUCTION VERSUS ACCESSORY AV PATHWAY CONDUCTION
- TACHYCARDIAS REQUIRING AN AV ACCESSORY PATHWAY FOR INITIATION AND MAINTENANCE
- Orthodromic AVRT
- - ECG findings in orthodromic AVRT
- Antidromic AVRT
- - ECG findings in antidromic AVRT
- Permanent junctional reciprocating tachycardia
- - ECG findings in PJRT
- CLINICAL MANIFESTATIONS OF AVRT AND PJRT
- DIAGNOSIS OF AVRT AND PJRT
- DIFFERENTIAL DIAGNOSIS
- TREATMENT OF AVRT AND PJRT
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS