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Variability of the VA interval at tachycardia induction: a simple method to differentiate orthodromic reciprocating tachycardia from atypical atrioventricular nodal reentrant tachycardia

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Abstract

Background

The differential diagnosis between orthodromic atrioventricular reentry tachycardia (AVRT) and atypical AV nodal reentrant tachycardia (aAVNRT) is sometimes challenging. We hypothesize that aAVNRTs have more variability in the retrograde conduction time at tachycardia onset than AVRTs.

Methods

We aimed to assess the variability in retrograde conduction time at tachycardia onset in AVRT and aAVNRT and to propose a new diagnostic tool to differentiate these two arrhythmia mechanisms. We measured the VA interval of the first beats after tachycardia induction until it stabilized. The difference between the maximum and minimum VA intervals (∆VA) and the number of beats needed for the VA interval to stabilize was analyzed. Atrial tachycardias were excluded.

Results

A total of 107 patients with aAVNRT (n = 37) or AVRT (n = 64) were included. Six additional patients with decremental accessory pathway-mediated tachycardia (DAPT) were analyzed separately. All aAVNRTs had VA interval variability. The median ∆VA was 0 (0 − 5) ms in AVRTs vs 40 (21 − 55) ms in aAVNRTs (p < 0.001). The VA interval stabilized significantly earlier in AVRTs (median 1.5 [1 − 3] beats) than in aAVNRTs (5 [4 − 7] beats; p < 0.001). A ∆VA < 10 ms accurately differentiated AVRT from aAVNRT with 100% of sensitivity, specificity, and positive and negative predictive values. The stabilization of the VA interval at < 3 beats of the tachycardia onset identified AVRT with sensitivity, specificity, and positive and negative predictive values of 64.1%, 94.6%, 95.3%, and 60.3%, respectively. A ∆VA < 20 ms yielded good diagnostic accuracy for DAPT.

Conclusions

A ∆VA < 10 ms is a simple and useful criterion that accurately distinguished AVRT from atypical AVNRT.

Graphical abstract

Central panel: Scatter plot showing individual values of ∆VA in atypical AVNRT and AVRT. Left panel: induction of atypical AVNRT. The VA interval stabilizes at the 5th beat and the ∆VA is 62 ms (maximum VA interval: 172 ms – minimum VA interval: 110 ms). Right panel: induction of AVRT. The tachycardia has a fixed VA interval from the first beat. ∆VA is 0 ms.

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Data availability

The data underlying this article will be shared upon reasonable request to the corresponding author.

Code availability

Not applicable.

Abbreviations

AVRT:

Atrioventricular reentry tachycardia

AVNRT:

Atrioventricular nodal reentrant tachycardia

AP:

Accessory pathway

AUC:

Area under the ROC curve

PPV:

Positive predictive value

NPV:

Negative predictive value

RV:

Right ventricle

SVT:

Supraventricular tachycardia

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Authors and Affiliations

  1. Hospital General de Agudos Dr. Cosme Argerich, Pi y Margall 750, 1155, Ciudad Autónoma de Buenos Aires, Argentina

    Claudio Hadid, Leonardo Celano, Darío Di Toro, Edgar Antezana-Chavez & Carlos Labadet

  2. Hospital Universitario CEMIC, Ciudad Autónoma de Buenos Aires, Argentina

    Claudio Hadid, Leonardo Celano, Darío Di Toro & Carlos Labadet

  3. Sanatorio Garat, Concordia, Entre Ríos, Argentina

    Claudio Hadid & Sebastián Gallino

  4. Cardiovascular Chivilcoy, Chivilcoy, Buenos Aires, Argentina

    Claudio Hadid & Gustavo Iralde

  5. Arrhythmia Unit, Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria de Asturias, Oviedo, Spain

    David Calvo

  6. Cardiology Department, Hospital General Universitario Gregorio Marañon, Instituto de Investigación Sanitaria Gregorio Marañon, Madrid, Spain

    Pablo Ávila

  7. Centre for Biomedical Research in Cardiovascular Disease Network (CIBERCV), Madrid, Spain

    Pablo Ávila

  8. Sanatorio del Salvador, Córdoba, Argentina

    Leonardo Atea

  9. Instituto de Cardiología, Tucumán, Argentina

    Sergio Gonzalez

  10. Hospital Prof. Dr. Juan Garrahan, Buenos Aires, Argentina

    Sebastián Maldonado

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  1. Claudio Hadid
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Correspondence to Claudio Hadid.

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Hadid, C., Celano, L., Di Toro, D. et al. Variability of the VA interval at tachycardia induction: a simple method to differentiate orthodromic reciprocating tachycardia from atypical atrioventricular nodal reentrant tachycardia. J Interv Card Electrophysiol 66, 637–645 (2023). https://doi.org/10.1007/s10840-022-01376-w

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