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Benefits and potential risks of atrial antitachycardia pacing after repair of congenital heart disease. Pacing Clin Electrophysiol 1995; 18:1005. Topic 937 Version 28.0 https://www.uptodate.com/contents/intraatrial-reentrant-tachycardia/print 14/24 7/5/23, 10:24 AM Intraatrial reentrant tachycardia - UpToDate GRAPHICS Reentrant circuit of typical atrial flutter within the right atrium Schematic representation of reentrant circuit (red arrow) of typical (type 1) atrial flutter. The reentrant impulse rotates in a counterclockwise direction around the tricuspid annulus. The crista terminalis (CT) and eustacian ridge (ER) serve as lines of block, preventing the impulse from short-circuiting the annulus. Ablation is performed in the isthmus between the IVC and TA, which is an obligatory part of the circuit. SVC: superior vena cava; CS: coronary sinus; IVC: inferior vena cava; FO: foramen ovale Graphic 52904 Version 5.0 https://www.uptodate.com/contents/intraatrial-reentrant-tachycardia/print 15/24 7/5/23, 10:24 AM Intraatrial reentrant tachycardia - UpToDate Sites of reentry in supraventricular tachyarrhythmias Reentry may occur around a fixed anatomic obstacle or may be functional, developing in the absence of an anatomic obstacle and resulting from the intrinsic heterogeneity of electrophysiologic properties of the myocardial tissue. Reentrant circuits leading to a supraventricular tachyarrhythmia may develop in various parts of the heart: within and around the sinoatrial node (sinus node reentry); within the atrial myocardium (atrial tachycardia, atrial flutter, or atrial fibrillation); within the atrioventricular (AV) node due to the presence of a slow and fast pathway (atrioventricular nodal reentrant tachycardia); or involving the AV node and an accessory pathway (AP) (atrioventricular reentrant tachycardia). LAF: left anterior fascicle; LPF: left posterior fascicle. Graphic 82249 Version 4.0 https://www.uptodate.com/contents/intraatrial-reentrant-tachycardia/print 16/24 7/5/23, 10:24 AM Intraatrial reentrant tachycardia - UpToDate Electrocardiogram in atrial tachycardia suggesting left atrial origin of the arrhythmia Leads aVL and V1 show a regular narrow QRS complex tachycardia with P waves present before each QRS complex. The P waves are abnormal when compared with those during sinus rhythm occurring after the tachycardia breaks (arrow). The P wave morphology - negative in aVL, positive in V1 - suggests a left atrial origin. Graphic 73578 Version 4.0 https://www.uptodate.com/contents/intraatrial-reentrant-tachycardia/print 17/24 7/5/23, 10:24 AM Intraatrial reentrant tachycardia - UpToDate Electrophysiologic characteristics of the different types of supraventricular tachycardia (SVT) Characteristic Reentrant Triggered Automatic Initiation by extrastimuli and/or continuous pacing Yes Yes No Initiation by continuous pacing depends upon the rate No Yes No and number of stimuli Termination by extrastimuli Yes No No Termination by continuous pacing (overdrive) Yes Yes No Overdrive suppression of tachycardia No No Yes Overdrive enhancement of tachycardia Yes Yes No Entrainment possible Yes No No First P wave identical to P waves in arrhythmia No Sometimes Yes Warm-up or acceleration of pacemaker after onset No Sometimes Yes Graphic 53347 Version 2.0 https://www.uptodate.com/contents/intraatrial-reentrant-tachycardia/print 18/24 7/5/23, 10:24 AM Intraatrial reentrant tachycardia - UpToDate Electrophysiology study (EPS) tracing during mapping of atrial tachycardia Shown are three surface electrocardiogram (ECG) leads (I, aVF, V1) and intracardiac recordings from the high posterior right atrium (HRA); posterior left atrium (USER1 and USER 3); proximal, mid, and distal coronary sinuses (CS9-10, CS5-6, CS1-2); and right ventricular apex (RVA). The patient had an incessant atrial tachycardia and dilated cardiomyopathy (left ventricular ejection fraction 9 percent) referred for cardiac transplant evaluation. The P wave (*) falls at the end of the T wave in the surface ECG; its onset is difficult to discern. However, the intracardiac electrograms demonstrate obvious atrial (A) and ventricular (V) activity. Activation mapping involves positioning the mapping catheters in the right (HRA) and left atria (USER) to record earliest electrical activity during the tachycardia. The left atrial catheter records earlier electrical activity (arrow) than the right atrial catheter, but the timing with respect to the surface P wave is obscured because of the T wave of the preceding QRS complex. Graphic 58120 Version 7.0 https://www.uptodate.com/contents/intraatrial-reentrant-tachycardia/print 19/24 7/5/23, 10:24 AM Intraatrial reentrant tachycardia - UpToDate Electrophysiologic (EP) study tracing showng a ventricular premature beat (VPB) during mapping of an atrial tachycardia Three surface ECG leads (I, aVF, V1) and intracardiac recordings from the high posterior right atrium (HRA); posterior left atrium (USER1 and USER 3); proximal, mid, and distal coronary sinus (CS9-10, CS5-6, CS1-2); and right ventricular apex (RVA) in a patient with atrial tachycardia. A ventricular premature beat (VPB) introduced from the right ventricular outflow tract has no effect on the underlying atrial tachycardia, but the onset of the P wave (P) in the surface ECG recordings can be seen more clearly as it is no longer superimposed on the T wave. The atrial electrogram (A) recorded from the right atrial catheter precedes the surface P wave by 30 msec, but the signal from the left atrial catheter (USER1) precedes the surface P wave by 50 msec (arrow). V: ventricular electrogram. Graphic 50219 Version 3.0 https://www.uptodate.com/contents/intraatrial-reentrant-tachycardia/print 20/24 7/5/23, 10:24 AM Intraatrial reentrant tachycardia - UpToDate Electrophysiology (EP) study tracing obtained during radiofrequency catheter ablation of atrial tachycardia Three surface ECG leads (I, aVF, V1) and intracardiac recordings from the high posterior right atrium (HRA); posterior left atrium (USER1 and USER 3); proximal, mid, and distal coronary sinus (CS9-10, CS5-6, CS1-2); and right ventricular apex (RVA) in a patient with atrial tachycardia. Radiofrequency energy application at the left atrial site of earliest atrial activation (USER1) causes initial rate acceleration, consistent with heating of an automatic focus; this is followed by abrupt termination (*) of the atrial tachycardia, resulting in a junctional rhythm. The patient had no further tachycardia during follow-up and left ventricular function returned to normal within four months of the ablation procedure, confirming that the cardiomyopathy was tachycardia induced. Graphic 82052 Version 3.0 https://www.uptodate.com/contents/intraatrial-reentrant-tachycardia/print 21/24 7/5/23, 10:24 AM Intraatrial reentrant tachycardia - UpToDate Revised (2018) Vaughan Williams classification of antiarrhythmic drugs abridged table Class 0 (HCN channel blockers) Ivabradine Class I (voltage-gated Na+ channel blockers) Class Ia (intermediate dissociation): Quinidine, ajmaline, disopyramide, procainamide Class Ib (rapid dissociation): Lidocaine, mexilitine Class Ic (slow dissociation): Propafenone, flecainide Class Id (late current): Ranolazine Class II (autonomic inhibitors and activators) Class IIa (beta blockers): Nonselective: carvedilol, propranolol, nadolol Selective: atenolol, bisoprolol, betaxolol, celiprolol, esmolol, metoprolol Class IIb (nonselective beta agonists): Isoproterenol Class IIc (muscarinic M2 receptor inhibitors): Atropine, anisodamine, hyoscine, scopolamine Class IId (muscarinic M2 receptor activators): Carbachol, pilocarpine, methacholine, digoxin Class IIe (adenosine A1 receptor activators): Adenosine Class III (K+ channel blockers and openers) Class IIIa (voltage dependent K+ channel blockers): Ambasilide, amiodarone, dronedarone, dofetilide, ibutilide, sotalol, vernakalant Class IIIb (metabolically dependent K+ channel openers): https://www.uptodate.com/contents/intraatrial-reentrant-tachycardia/print 22/24 7/5/23, 10:24 AM Intraatrial reentrant tachycardia - UpToDate Nicorandil, pinacidil Class IV (Ca++ handling modulators) Class IVa (surface membrane Ca++ channel blockers): Bepridil, diltiazem, verapamil Class IVb (intracellular Ca++ channel blockers): Flecainide, propafenone Class V (mechanosensitive channel blockers): No approved medications Class VI (gap junction channel blockers) No approved medications Class VII (upstream target modulators) Angiotensin converting enzyme inhibitors Angiotensin receptor blockers Omega-3 fatty acids Statins HCN: hyperpolarization-activated cyclic nucleotide-gated; Na: sodium; K: potassium; Ca: calcium. Graphic 120433 Version 3.0 https://www.uptodate.com/contents/intraatrial-reentrant-tachycardia/print 23/24 7/5/23, 10:24 AM Intraatrial reentrant tachycardia - UpToDate Contributor Disclosures Munther K Homoud, MD Speaker's Bureau: Abbott [Live heart dissection]. All of the relevant financial relationships listed have been mitigated. Samuel L vy, MD No relevant financial relationship(s) with ineligible companies to disclose. Susan B Yeon, MD, JD, FACC No relevant financial relationship(s) with ineligible companies to disclose. Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence. Conflict of interest policy https://www.uptodate.com/contents/intraatrial-reentrant-tachycardia/print 24/24