Local VA index for the differential diagnosis of supraventricular tachycardia

Benjamin Bouyer; Nicolas Derval; Thomas Pambrun; Romain Tixier; Marine Arnaud; Samuel Buliard; Rémi Chauvel; Hugo Marchand; Xavier Bouteiller; Konstantinos Vlachos; Ciro Ascione; Masaaki Yokoyama; Christopher Kowalewski; Mélèze Hocini; Pierre Jaïs; Frederic Sacher; Michel Haïssaguerre; Josselin Duchateau

doi:10.1016/j.hrthm.2024.01.042

Local VA index for the differential diagnosis of supraventricular tachycardia

Heart Rhythm. 2024 Jan 27:S1547-5271(24)00096-1. doi: 10.1016/j.hrthm.2024.01.042. Online ahead of print.

Authors

Benjamin Bouyer¹, Nicolas Derval², Thomas Pambrun², Romain Tixier², Marine Arnaud², Samuel Buliard², Rémi Chauvel², Hugo Marchand², Xavier Bouteiller², Konstantinos Vlachos², Ciro Ascione², Masaaki Yokoyama², Christopher Kowalewski², Mélèze Hocini², Pierre Jaïs², Frederic Sacher², Michel Haïssaguerre², Josselin Duchateau²

Affiliations

¹ Hôpital Cardiologique du Haut Lévêque, CHU Bordeaux, Pessac, France; IHU LIRYC (L'Institut de Rythmologie et Modélisation Cardiaque), Université de Bordeaux, Pessac, France. Electronic address: benjamin.bouyer@chu-bordeaux.fr.
² Hôpital Cardiologique du Haut Lévêque, CHU Bordeaux, Pessac, France; IHU LIRYC (L'Institut de Rythmologie et Modélisation Cardiaque), Université de Bordeaux, Pessac, France.

PMID: 38286245
DOI: 10.1016/j.hrthm.2024.01.042

Abstract

Background: Differentiating between atypical atrioventricular nodal reentrant tachycardia (AVNRT) and orthodromic reciprocating tachycardia utilizing a septal accessory pathway is a complex challenge.

Objective: The purpose of this study was to describe the "local VA index," a straightforward method based on signals from the coronary sinus catheter, to distinguish between these arrhythmias during tachycardia and entrainment. The ventriculoatrial (VA) interval on the coronary sinus catheter is measured during tachycardia and entrainment, at the site of earliest atrial activity. The difference between these 2 situations defines the "local VA index." We also propose a mechanism to clarify the limitations of historical pacing maneuvers, such as postpacing interval minus tachycardia cycle length (PPI-TCL) and stimulus-atrial interval minus ventriculoatrial interval (SA-VA), by examining nodal decrement and intraventricular conduction delay.

Methods: In a retrospective study of 75 patients referred for supraventricular tachycardia evaluation, 37 were diagnosed with atrioventricular reentrant tachycardia (AVRT) with orthodromic reciprocating tachycardia, and 38 with AVNRT (27 typical, 11 atypical).

Results: In comparison to AVRT patients, AVNRT patients exhibited longer PPI-TCL (176 ± 47 ms vs 113 ± 42 ms; P <.01) and SA-VA (138 ± 47 ms vs 64 ± 28 ms; P <.01). The AVRT group had mean local VA index of -1 ± 13 ms, whereas the AVNRT group had a significantly longer index of 91 ± 46 ms (P <.01). An optimal threshold for differentiation was a local VA index of 40 ms. Importantly, there was no significant correlation between pacing cycle length and nodal decrement as well as intraventricular delay related to pathway location. This interindividual variability might explain misleading interpretations of PPI-TCL and SA-VA.

Conclusion: This novel approach is advantageous because of its simplicity and effectiveness, requiring only 2 diagnostic catheters. A local VA interval difference <40 ms provides a clear distinction for AVRT.

Keywords: Atrioventricular nodal reentrant tachycardia; Atrioventricular reentrant tachycardia; Electrophysiology; Pacing maneuver; Supraventricular tachycardia.