| Summary: | Differentiation between atrioventricular reentrant tachycardia (AVRT) and AV nodal reentrant tachycardia (AVNRT) can be sometimes challenging in the EP lab. RV pacing during SVT produces progressive QRS fusion before QRS morphology becomes stable. This fusion zone (FZ) may differentiate AVRT from AVNRT independent of entrainment success. PPI-TCL during RV entrainment can help in differentiation; however it has some fallacies and limitations. We thought to compare the accuracy of atrial preexcitation (AP) & Stimulus to atrial (S-A) interval fixation in relation to fusion zone in identifying the mechanism of SVT.
We studied retrospectively and prospectively the effect of properly timed RVP on atrial timing during FZ. 118 SVT patients had RVP within 40 ms shorter than tachycardia cycle length (TCL). S–A interval and atrial CL were measured during FZ and with each QRS complex thereafter. A fixed S–A interval was defined as variation <5 ms during RVP & AP is the first change in atrial CL ⩾ 10 ms.
9 patients were excluded due to cycle length oscillation > 10 ms before the onset of RVP and 6 patients had atrial tachycardia (VA dissociation with RVP) and were excluded. In the remaining 103 patients, PPI-TCL was significantly longer in AVNRT patients but postpacing response couldn’t be assessed in 12 patients who showed consistent termination of tachycardia during RVP entrainments; 3 AVNRT patients (5%) & 9 AVRT patients (22%). And when assessed it was not diagnostic in additional 4 (6%) patients with AVNRT (<115 ms) & 7 (17%) patients with ORT (⩾115 ms). Atrial pre-excitation (AP) occurred during FZ in most AVRT patients and after FZ in most AVNRT patients. However, S-A fixation occurred during FZ in all AVRT patients and after FZ in all AVNRT patients. Fixation of S-A interval in relation to FZ was more accurate than either AP or PPI-TCL in identifying the mechanism of SVT (100%, 92.4% and 84.8% consecutively).
We can conclude that during RVP within 40 ms of the tachycardia cycle length, fixed S–A interval and AP in relation to FZ were superior to PPI-TCL measurement in identifying the mechanism of SVT.
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