Atrioventricular Node Reentry Supraventricular Tachycardia Treatment & Management

  • Author: Glenn T Wetzel, MD, PhD; Chief Editor: Stuart Berger, MD   more...
 
Updated: Apr 12, 2012
 

Medical Care

Emergency treatment of patients with hemodynamic instability such as atrioventricular node reentrant tachycardia (AVNRT) is directed at converting the rhythm to sinus through a brief episode of atrioventricular (AV) block.

  • Perform synchronized electrical cardioversion if patients have a deteriorating condition or if there is no response to the initial attempts of conversion (see below).
  • As in any other mechanism of supraventricular tachycardia (SVT), the use of vagal maneuvers can be very helpful in the acute setting.
    • In the infant, apply a plastic bag containing ice cubes and water to the face for 25-30 seconds to induce the diving reflex, a vagal stimulus. In older children, other vagal maneuvers can be attempted, such as breathholding or Valsalva maneuver.
    • If this is not successful, the next step is to administer medication. The drug of choice is adenosine, administered from an intravenous site as close as possible to the heart. Importantly, data have indicated low efficacy of recommended doses of adenosine, therefore suggesting the need to redefine current guidelines. Use of esmolol, a short-acting beta-blocker, also has been successful.
  • Esophageal overdrive atrial pacing is also quite safe and effective in converting to sinus rhythm.
  • Recording of a long 3- or 12-lead rhythm strip during attempts to terminate the tachycardia may be invaluable in subsequent efforts to define the mechanism of SVT and should be routinely performed.
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Surgical Care

  • Knowledge of the anatomy of the Koch triangle (ie, where the AV node is located) is needed to understand how atrioventricular node reentry (AVNR) ablation is performed.[8] The Koch triangle is defined by the ostium of the coronary sinus posteriorly. The apex of the triangle is defined anteriorly by the His bundle. The tendon of Todaro and the tricuspid valve annulus comprise the sides of the triangle. In the electrophysiology laboratory, landmarks of the Koch triangle are identified by one catheter recording the His deflection and by a second catheter placed in the ostium of the coronary sinus. The Koch triangle is located between these 2 catheters.
  • The fast pathway is anteriorly located, along the tendon of Todaro. The slow pathway is posterior-inferiorly located, along the tricuspid annulus, near the ostium of the coronary sinus.
  • The electrophysiologic signal is equally important to the anatomic location for determination of appropriate ablation targets.
  • Ablation of AVNR is accomplished by delivering either radiofrequency or cryothermal energy over the slow pathway. Because its location is more posterior and, thus, distant from the AV node, incidence of complete heart block with the use of radiofrequency energy is low (1.2%). The overall success rate of radiofrequency ablation on AVNRT has been more than 98% over the past several years.
  • Cryothermal energy has allowed catheter mapping of specific ablation targets. This is especially advantageous in children with AVNRT because it allows reversibility of conduction block, decreasing the risk of complete AV block. The cryolesion becomes irreversible at temperatures below -70ºC. The use of cryothermal energy to map and ablate arrhythmia substrates has been shown to be safer than radiofrequency energy; however, this safety comes at the expense of acutely lower success rates and higher recurrence rates at midterm follow-up.
  • Success rates of 83% were achieved for pediatric AVNRT cryoablation in a multicenter study. No complications were reported, and, subsequently, the success rate for radiofrequency ablation in the 4 AVNRT cryoablation failures was 100% with the combined approach.
  • In another series, 14 pediatric patients with AVNRT had cryoablation success rates of 92.8%, with no complications and a recurrence rate of 30% for AVNRT in 22 months of follow-up.
  • One study of pediatric patients showed a trend toward improved initial success rates (98% vs 93%) and lower early recurrence rates (9% vs 18%) using a 6-mm tip cryoablation catheter as compared with a 4-mm tip catheter.[9]
  • With the use of radiofrequency energy, the AV node can be modified, usually at the slow pathway, with a large-tipped catheter in the same procedure as the electrophysiologic study. The approaches to AV node slow pathway modification are generally anatomical (ie, creating a line or lines of block across the usual site of the slow-pathway entrance) or guided by slow-pathway potentials. Successful deliveries of energy often are associated with a smooth and gradual acceleration of junctional tachycardia. AV conduction must be assessed carefully during energy application to ensure that heart block is not created. Successful ablation usually is associated with a loss of the jump in conduction, fewer or no AV nodal echo beats, and failure to re-induce tachycardia.
  • With cryothermal energy, the advantage of creating a map for subsequent ablation has been partly obscured by the finding that, in some patients, the mapped location does not predict the actual successful spot, with a reported negative predictive value of 66% in some series. Also, transient AV block was noted in other patients, where the map has previously shown to be a safe location. So far, no permanent AV block has been described with cryomapping/ablation; however, the patient numbers are still small.
  • Postcatheterization complications include hemorrhage, pain, nausea and vomiting, rhythm abnormalities, and arterial or venous obstruction from thrombosis or spasm.
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Diet

Patients with AVNRT should avoid caffeine-containing items so that SVT is not provoked by caffeine-induced premature beats.

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Contributor Information and Disclosures
Author

Glenn T Wetzel, MD, PhD  Professor of Pediatrics, University of Tennessee College of Medicine; Director, Pediatric Arrhythmia Service, Le Bonheur Children's Medical Center

Glenn T Wetzel, MD, PhD is a member of the following medical societies: American Academy of Pediatrics, American Heart Association, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Coauthor(s)

Ryan Jones, MD  Fellow, Division of Pediatric Cardiology, Department of Pediatrics, University of Tennessee Health Science Center, Memphis

Ryan Jones, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Cardiology

Disclosure: Nothing to disclose.

Specialty Editor Board

Charles I Berul, MD  Professor of Pediatrics and Integrative Systems Biology, George Washington University School of Medicine; Chief, Division of Cardiology, Children's National Medical Center

Charles I Berul, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American Heart Association, Cardiac Electrophysiology Society, Heart Rhythm Society, Pediatric and Congenital Electrophysiology Society, and Society for Pediatric Research

Disclosure: Johnson & Johnson Consulting fee Consulting

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Hugh D Allen, MD  Professor, Department of Pediatrics, Division of Pediatric Cardiology and Department of Internal Medicine, Ohio State University College of Medicine

Hugh D Allen, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American Heart Association, American Pediatric Society, American Society of Echocardiography, Society for Pediatric Research, Society of Pediatric Echocardiography, and Western Society for Pediatric Research

Disclosure: Nothing to disclose.

Gilbert Z Herzberg, MD  Assistant Professor, Department of Pediatrics, Section of Pediatric Cardiology, New York Medical College; Consulting Staff, Department of Pediatrics, Sound Shore Medical Center

Gilbert Z Herzberg, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Chief Editor

Stuart Berger, MD  Professor of Pediatrics, Division of Cardiology, Medical College of Wisconsin; Chief of Pediatric Cardiology, Medical Director of Pediatric Heart Transplant Program, Medical Director of The Heart Center, Children's Hospital of Wisconsin

Stuart Berger, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American College of Chest Physicians, American Heart Association, and Society for Cardiac Angiography and Interventions

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors Robert Hamilton, MD, and Rejane Dillenburg, MD, to the development and writing of this article.

References

  1. Lee KW, Badhwar N, Scheinman MM. Supraventricular tachycardia--part I. Curr Probl Cardiol. Sep 2008;33(9):467-546. [Medline].

  2. Van Hare GF. Developmental aspects of atrioventricular node reentry tachycardia. J Electrocardiol. Nov-Dec 2008;41(6):480-2. [Medline].

  3. Van Hare, GF. Developmental aspects of atrioventricular node reentry tachycardia. Journal of Electrocardiology. 2008;41:480-482. [Medline].

  4. Thapar MK, Gillette PC. Dual atrioventricular nodal pathways: a common electrophysiologic response in children. Circulation. Dec 1979;60(6):1369-74. [Medline].

  5. Segal OR, Gula LJ, Skanes AC, Krahn AD, Yee R, Klein GJ. Differential ventricular entrainment: a maneuver to differentiate AV node reentrant tachycardia from orthodromic reciprocating tachycardia. Heart Rhythm. Apr 2009;6(4):493-500. [Medline].

  6. Perez-Rodon J, Bazan V, Bruguera-Cortada J, et al. Entrainment from the para-Hisian region for differentiating atrioventricular node reentrant tachycardia from orthodromic atrioventricular reentrant tachycardia. Europace. Oct 2008;10(10):1205-11. [Medline].

  7. Katritsis DG, Camm AJ. Classification and differential diagnosis of atrioventricular nodal re-entrant tachycardia. Europace. Jan 2006;8(1):29-36. [Medline].

  8. Dobreanu D, Micu S, Toma O, Rudzik R. Intraprocedural predictors of successful ablation of slow pathway for atrioventricular nodal reentrant tachycardia. Rom J Intern Med. 2007;45(1):35-46. [Medline].

  9. Chanani NK, Chiesa NA, Dubin AM, Avasarala K, Van Hare GF, Collins KK. Cryoablation for atrioventricular nodal reentrant tachycardia in young patients: predictors of recurrence. Pacing Clin Electrophysiol. Sep 2008;31(9):1152-9. [Medline].

  10. Ratnasamy C, Rossique-Gonzalez M, Young ML. Pharmacological therapy in children with atrioventricular reentry: which drug?. Curr Pharm Des. 2008;14(8):753-61. [Medline].

  11. Shah A, Moon-Grady A, Bhogal N, Collins KK, Tacy T, Brook M, et al. Effectiveness of Sotalol as First-Line Therapy for Fetal Supraventricular Tachyarrhythmias. Am J Cardiol. Mar 21 2012;[Medline].

  12. Benson DW Jr, Dunnigan A, Benditt DG, et al. Transesophageal study of infant supraventricular tachycardia: electrophysiologic characteristics. Am J Cardiol. Nov 1 1983;52(8):1002-6. [Medline].

  13. Calkins H, Yong P, Miller JM, et al. Catheter ablation of accessory pathways, atrioventricular nodal reentrant tachycardia, and the atrioventricular junction: final results of a prospective, multicenter clinical trial. The Atakr Multicenter Investigators Group. Circulation. Jan 19 1999;99(2):262-70. [Medline].

  14. Cohen MI, Wieand TS, Rhodes LA, Vetter VL. Electrophysiologic properties of the atrioventricular node in pediatric patients. J Am Coll Cardiol. Feb 1997;29(2):403-7. [Medline].

  15. Dixon J, Foster K, Wyllie J, Wren C. Guidelines and adenosine dosing in supraventricular tachycardia. Arch Dis Child. Nov 2005;90(11):1190-1. [Medline].

  16. Drago F, De Santis A, Grutter G, Silvetti MS. Transvenous cryothermal catheter ablation of re-entry circuit located near the atrioventricular junction in pediatric patients: efficacy, safety, and midterm follow-up. J Am Coll Cardiol. Apr 5 2005;45(7):1096-103. [Medline].

  17. Epstein MR, Saul JP, Fishberger SB, et al. Spontaneous accelerated junctional rhythm: an unusual but useful observation prior to radiofrequency catheter ablation for atrioventricular node reentrant tachycardia in young patients. Pacing Clin Electrophysiol. Jun 1997;20(6):1654-61. [Medline].

  18. Etheridge SP. Cryoablation for supraventricular tachycardia in children: is it okay to trade success for decreased risk?. J Cardiovasc Electrophysiol. Sep 2005;16(9):967-8. [Medline].

  19. Figa F, Chiu C, Gow RM. Unusual electrophysiological findings in atrioventricular node reentrant tachycardia. Pacing Clin Electrophysiol. Jun 1995;18(6):1324-6. [Medline].

  20. Goldberger J, Brooks R, Kadish A. Physiology of "atypical" atrioventricular junctional reentrant tachycardia occurring following radiofrequency catheter modification of the atrioventricular node. Pacing Clin Electrophysiol. Dec 1992;15(12):2270-82. [Medline].

  21. Hayes JJ, Sharma PP, Smith PN, Vidaillet HJ. Familial atrioventricular nodal reentry tachycardia. Pacing Clin Electrophysiol. Jan 2004;27(1):73-6. [Medline].

  22. Josephson ME, Wellens HJ. Differential diagnosis of supraventricular tachycardia. Cardiol Clin. Aug 1990;8(3):411-42. [Medline].

  23. Kirsh JA, Gross GJ, O'Connor S, Hamilton RM. Transcatheter cryoablation of tachyarrhythmias in children: initial experience from an international registry. J Am Coll Cardiol. Jan 4 2005;45(1):133-6. [Medline].

  24. Kriebel T, Broistedt C, Kroll M, et al. Efficacy and safety of cryoenergy in the ablation of atrioventricular reentrant tachycardia substrates in children and adolescents. J Cardiovasc Electrophysiol. Sep 2005;16(9):960-6. [Medline].

  25. Miyazaki A, Blaufox AD, Fairbrother DL, Saul JP. Prolongation of the fast pathway effective refractory period during cryoablation in children: a marker of slow pathway modification. Heart Rhythm. Nov 2005;2(11):1179-85. [Medline].

  26. Okumura Y, Watanabe I, Yamada T, et al. Comparison of coronary sinus morphology in patients with and without atrioventricular nodal reentrant tachycardia by intracardiac echocardiography. J Cardiovasc Electrophysiol. Mar 2004;15(3):269-73. [Medline].

  27. Rhodes LA, Wieand TS, Vetter VL. Low temperature and low energy radiofrequency modification of atrioventricular nodal slow pathways in pediatric patients. Pacing Clin Electrophysiol. Jul 1999;22(7):1071-8. [Medline].

  28. Silka MJ, Halperin BD, Hardy BG, et al. Safety and efficacy of radiofrequency modification of slow pathway conduction in children < or = 10 years of age with atrioventricular node reentrant tachycardia. Am J Cardiol. Nov 15 1997;80(10):1364-7. [Medline].

  29. Silka MJ, Kron J, Halperin BD, et al. Mechanisms of AV node reentrant tachycardia in young patients with and without dual AV node physiology. Pacing Clin Electrophysiol. Nov 1994;17(11 Pt 2):2129-33. [Medline].

  30. Silka MJ, Kron J, Park JK, et al. Atypical forms of supraventricular tachycardia due to atrioventricular node reentry in children after radiofrequency modification of slow pathway conduction. J Am Coll Cardiol. May 1994;23(6):1363-9. [Medline].

  31. Teixeira OH, Balaji S, Case CL, et al. Radiofrequency catheter ablation of atrioventricular nodal reentrant tachycardia in children. Pacing Clin Electrophysiol. Oct 1994;17(10):1621-6. [Medline].

  32. Van Hare GF, Chiesa NA, Campbell RM, et al. Atrioventricular nodal reentrant tachycardia in children: effect of slow pathway ablation on fast pathway function. J Cardiovasc Electrophysiol. Mar 2002;13(3):203-9. [Medline].

  33. Wolff GS, Sung RJ, Pickoff A, et al. The fast-slow form of atrioventricular nodal reentrant tachycardia in children. Am J Cardiol. Jun 1979;43(6):1181-8. [Medline].

  34. Wu D, Denes P, Amat-Y-Leon F, et al. An unusual variety of atrioventricular nodal re-entry due to retrograde dual atrioventricular nodal pathways. Circulation. Jul 1977;56(1):50-9. [Medline].

 
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The patient's heart rate is approximately 146 beats per minute with a normal axis. Note the pseudo S waves in leads II, III, and aVF. Also note the pseudo R' waves in V1 and aVR. These deflections represent retrograde atrial activation.
 
 
 
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