Atrioventricular Node Reentry Supraventricular Tachycardia Workup

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

Laboratory Studies

  • Upon initial presentation of atrioventricular node reentrant tachycardia (AVNRT), assessments of serum electrolyte levels, thyroid function, and hemoglobin are often performed.
  • Other laboratory studies may be performed to monitor serum levels and adverse effects in children receiving antiarrhythmic medications.
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Imaging Studies

  • Chest radiography and echocardiography are often performed to evaluate the degree of cardiopulmonary dysfunction associated with the tachyarrhythmia and to assess for structural abnormalities.
  • Clinical and experimental studies using electrophysiological and electroanatomical mapping are adding to the understanding of the anatomy and physiology of this disorder.
  • The coronary sinus, imaged at the time of electrophysiologic study, may have a broader opening in patients with AVNRT. This has not been confirmed.
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Other Tests

The ECG obtained during normal sinus rhythm shows a normal PR interval and the absence of preexcitation. Some patients may exhibit a slightly shortened PR interval or increased beat-to-beat variability of the PR interval, reflecting conduction through the fast or slow pathways. The typical AVNRT is characterized as a narrow complex regular tachycardia with rates that vary from 150-300 beats per minute. Unlike AV reentrant tachycardia (WPW or accessory pathway mediated tachycardia), AVNRT may exhibit AV dissociation with block to either the atrium (1:2 conduction) or to the ventricle (2:1 conduction).

  • Slow-fast form of AVNRT
    • The slow-fast form of AVNRT is typical.
    • Initiation of tachycardia usually occurs suddenly with a premature atrial beat. Sometimes, sudden sinus slowing is followed by a junctional escape beat as a trigger for the tachyarrhythmia.
    • The termination usually occurs with atrioventricular (AV) block, which is spontaneous or induced by vagal maneuvers or medications.
    • The rhythm may terminate with a P wave or QRS complex, depending on the site of block.
    • Little variability in RR intervals is usually noted.
    • The time that the impulse takes to reach the atrium and the ventricle from the distal node is approximately the same, which causes the retrograde P waves to be buried within the QRS or appear immediately preceding or at the terminal end of the QRS.
    • The RP interval is usually less than 50-70 milliseconds, which often results in the P wave being hidden in the QRS complex.
    • When the P wave is visible at the end of the QRS, it exhibits a characteristic late-positive component in ECG lead V1 (ie, pseudo-r' wave), or the retrograde P waves may simulate an S wave in the inferior leads.
  • Fast-slow form of AVNRT
    • The fast-slow form of AVNRT is atypical.
    • The trigger is usually a premature ventricular beat that blocks in the fast pathway and is conducted in a retrograde fashion through the slow pathway and then in an antegrade fashion through the fast pathway.
    • In this form, conduction to the atria takes longer than conduction to the ventricles, and the RP interval is longer than the PR interval.
    • Another characteristic is that the P wave axis is superior (ie, negative P waves in inferior leads), because the impulse is retrograde and originates in the AV node.
    • Distinguishing this tachycardia from permanent form of junctional reciprocating tachycardia (PJRT) is difficult, although PJRT usually presents with a more incessant rather than paroxysmal pattern.
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Procedures

  • The electrophysiological characteristics of AVNRT include initiation and termination of tachycardia by extrastimulus or rapid pacing; normal antegrade and retrograde AV conduction (with earliest retrograde activation at the His bundle); and termination with AV block that, although uncommon, may allow the AVNRT to persist. These characteristics can be evaluated in patients through the electrophysiological study (EPS), which may be semi-invasive (eg, esophageal electrode behind the heart) or intracardiac.
    • During the EPS, the presence of the 2 functional pathways in adult patients can usually be demonstrated with atrial extrastimulus testing.
    • As the atrial extrastimulus-coupling interval (A1-A2) is shortened by 10-millisecond decrements, the AV nodal conduction time following the atrial extrastimulus (A2-H2) increases gradually.
    • At a critical atrial-coupling interval, a 10-millisecond decrease in A1-A2 results in a marked increase (>50 ms) in A2-H2. This abrupt increase in AV nodal conduction time is termed a jump in conduction (discontinuous AH conduction curve), and it often is associated with the appearance of atrial echo beats or initiation of AVNRT.
    • Further 10-millisecond decreases in the A1-A2 interval result in small additional increases (< 50 ms) in the A2-H2 interval, or, less commonly, additional AH jumps are evident.
  • Some data indicate that AV nodal physiology in children is different than in adults. Based on the traditional definition of a 50-millisecond AH jump after a decrement of 10 milliseconds in the extrastimulus coupling interval, only 62% of the children in one study met criteria for dual AV node physiology. However, all patients had inducible AVNRT, and most of them were successfully ablated. The clinical importance of this finding is that children may not always fit the classic electrophysiologic criteria as it applies to adults; therefore, the endpoints for catheter ablation need to be readdressed and redefined in the pediatric population.
  • Another study demonstrated that the fast pathway effective refractory period (ERP) prolongs during AV node modification by cryotherapy, and this can be used as a marker of success. This study indicates that prolongation of more than 20 ms in the fast pathway ERP during cryotherapy application is 70% sensitive and 72% specific for predicting successful slow pathway modification. Subsequent to the procedure, the fast pathway ERP shortens to below baseline levels.
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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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