Atrioventricular Nodal Reentry Tachycardia (AVNRT) Workup

  • Author: Brian Olshansky, MD; Chief Editor: Jeffrey N Rottman, MD   more...
 
Updated: Feb 28, 2012
 

Imaging Studies

  • Echocardiogram - To evaluate for the presence of structural heart disease
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Other Tests

ECG or ambulatory monitoring

  • Evaluation usually reveals a supraventricular origin of QRS complexes at rates of 150-250 bpm and a regular rhythm.
  • The QRS complex is usually narrow unless a conduction abnormality is present or is functionally induced (aberrancy) from the rapid heart rate or the abrupt change in rate.
  • P waves are not usually seen because they are buried within the QRS complex. A pseudo R prime may be seen in V1, or pseudo S waves may be seen in leads II, III, or aVF. The onset is abrupt with an atrial premature complex, which conducts with a prolonged PR interval. Atypical atrioventricular nodal reentry includes fast antegrade slow retrograde conduction with a P wave before the QRS complex. Slow-slow atrioventricular nodal reentry can occur with a P wave occurring in mid diastole.
  • The PR interval may shorten over the first few beats at onset, or it may lengthen during last few beats preceding termination of the tachycardia.
  • Abrupt termination occurs with a retrograde P wave, sometimes followed by a brief period of asystole or bradycardia.
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Procedures

Electrophysiology study for diagnostic purposes and ablation for cure. Typical findings of AVNRT at electrophysiology study include dual node physiology, a discontinuous pattern of atrial-to-ventricular conduction reflecting the differing conduction properties of fast and slow antegrade conduction, and/or sustaining slow antegrade conduction, mimicking the superimposition of the P wave and QRS complex observed in the clinical arrhythmia. The most typical endpoint of ablation for AVNRT is modification or elimination of slow antegrade conduction associated with inability to induce the arrhythmia.

During the electrophysiology study, a "jump" in the AV node function curve, demonstrating 2 distinct physiologic AV nodal pathways, is one of the key findings indicating the presence of AV nodal reentry.

AV nodal reentry often starts with a premature atrial beat, a long AV interval followed by a retrograde rapid beat that is simultaneous or near simultaneous to the QRS complex. During ventricular pacing, retrograde activation is through the AV node and is demonstrated by early atrial activation in the His bundle electrogram.

Atypical AVNRT has fast activation antegrade through the AV node and slow activation retrograde that allows for early atrial activation to occur at a distinct time after the QRS complex and is earliest in the posterior septal right atrium. AVRT causes eccentric retrograde atrial activation.

In some instances, if an accessory pathway is septal, retrograde activation can mimic retrograde atrial activation through the AV node and this can be distinguished using adenosine administration with ventricular pacing, and in the use of ventricular extrastimuli during tachycardia that allows for preexcitation of the atria once the His bundle is refractory. Other interventions during the electrophysiology study may further distinguish AVNRT from AVRT, as well as determine if the tachycardia is due to atrial tachycardia, sinoatrial reentry, or ventricular tachycardia.

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Contributor Information and Disclosures
Author

Brian Olshansky, MD  Professor of Medicine, Department of Internal Medicine, University of Iowa College of Medicine

Brian Olshansky, MD is a member of the following medical societies: American College of Cardiology, American Heart Association, Cardiac Electrophysiology Society, and Heart Rhythm Society

Disclosure: Guidant/Boston Scientific Honoraria Speaking and teaching; Medtronic Honoraria Speaking and teaching; Guidant/Boston Scientific Consulting fee Consulting

Coauthor(s)

Renee M Sullivan, MD  Fellow, Division of Cardiovascular Medicine, University of Iowa Hospitals and Clinics

Renee M Sullivan, MD is a member of the following medical societies: American College of Cardiology, American College of Physicians, and American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Russell F Kelly  MD, Assistant Professor, Department of Internal Medicine, Rush Medical College; Chairman of Adult Cardiology and Director of the Fellowship Program, Cook County Hospital

Russell F Kelly is a member of the following medical societies: American College of Cardiology

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Marschall S Runge, MD, PhD  Charles and Anne Sanders Distinguished Professor of Medicine, Chairman, Department of Medicine, Vice Dean for Clinical Affairs, University of North Carolina at Chapel Hill School of Medicine

Marschall S Runge, MD, PhD is a member of the following medical societies: American Association for the Advancement of Science, American College of Cardiology, American College of Physicians-American Society of Internal Medicine, American Federation for Clinical Research, American Federation for Medical Research, American Heart Association, American Physiological Society, American Society for Clinical Investigation, American Society for Investigative Pathology, Association of American Physicians, Association of Professors of Cardiology, Association of Professors of Medicine, Southern Society for Clinical Investigation, and Texas Medical Association

Disclosure: Pfizer Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; Orthoclinica Diagnostica Consulting fee Consulting

Amer Suleman, MD  Private Practice

Amer Suleman, MD is a member of the following medical societies: American College of Physicians, American Heart Association, American Institute of Stress, American Society of Hypertension, Federation of American Societies for Experimental Biology, Royal Society of Medicine, and Society of Cardiac Angiography and Interventions

Disclosure: Nothing to disclose.

Chief Editor

Jeffrey N Rottman, MD  Professor of Medicine and Pharmacology, Vanderbilt University School of Medicine; Chief, Department of Cardiology, Nashville Veterans Affairs Medical Center

Jeffrey N Rottman, MD is a member of the following medical societies: American Heart Association and North American Society of Pacing and Electrophysiology (NASPE)

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous coauthors Shamila Garg, MD, and Marina Hannen, MD, Chirag M Sandesara, MD, Mukesh Garg, MD, MRCP, Annette Quick, MD, and Marco A Barzallo, MD to the development and writing of this article.

References

  1. Jackman WM, Beckman KJ, McClelland JH, et al. Treatment of supraventricular tachycardia due to atrioventricular nodal reentry, by radiofrequency catheter ablation of slow-pathway conduction. N Engl J Med. Jul 30 1992;327(5):313-8. [Medline].

  2. Braunwald E, ed. Heart Disease: A Textbook of Cardiovascular Medicine. 7th ed. Philadelphia, Pa: WB Saunders; 2004.

  3. Fogoros RN. Electrophysiologic Testing (Practical Cardiac Diagnosis). 3rd ed. London, UK: Blackwell Science; 1999.

  4. Gursoy S, Steurer G, Brugada J, et al. Brief report: the hemodynamic mechanism of pounding in the neck in atrioventricular nodal reentrant tachycardia. N Engl J Med. Sep 10 1992;327(11):772-4. [Medline].

  5. Janse MJ, Anderson RH, McGuire MA, Ho SY. "AV nodal" reentry: Part I: "AV nodal" reentry revisited. J Cardiovasc Electrophysiol. Oct 1993;4(5):561-72. [Medline].

 
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Electrophysiological mechanism of atrioventricular nodal reentry tachycardia.
Atypical atrioventricular nodal reentry tachycardia.
Typical atrioventricular nodal reentry tachycardia.
 
 
 
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