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Atrioventricular Nodal Reentry Tachycardia

AV nodal reentry tachycardia (AVNRT) is the most common form of paroxysmal supraventricular tachycardia (PSVT), representing ~60% of cases referred for catheter ablation. It most commonly manifests in the second to fourth decades of life, often in women. It is often well tolerated, but rapid tachycardia, particularly in the elderly, may cause angina, pulmonary edema, hypotension, or syncope. It is not usually associated with structural heart disease.

The mechanism is reentry involving the AV node and the perinodal atrium, made possible by the existence of multiple pathways for conduction from the atrium into the AV node that are capable of conduction in two directions (Fig. 244-1). Most forms of AVNRT utilize a slowly conducting AV nodal pathway (right inferior extension) that extends from the compact AV node near the His bundle, inferiorly along the tricuspid valve annulus to the floor of the coronary sinus. The reentry wavefront propagates up this slowly conducting pathway to the compact AV node and then exits from the fast pathway at the top of the AV node. The path back to the slow pathway probably involves the left atrial septum which has connections to the coronary sinus musculature. More unusual forms of AVNRT utilize a left inferior extension that connects to the compact AV node through the roof of the coronary sinus, or in extremely rare cases, directly from the mitral valve annulus avoiding the coronary sinus musculature altogether. In typical forms, the conduction time from the compact AV node region to the atrium is similar to that from the compact node to the His bundle and ventricles, such that atrial activation occurs at about the same time as ventricular activation. The p wave is therefore inscribed during, slightly before, or slightly after the QRS and can be difficult to discern. Often the P wave is seen at the end of the QRS complex as a pseudo-r′ in lead V1 and pseudo-S waves in leads II, III, and aVF (Fig. 244-1A). More unusual forms of AVNRT have P waves falling later, anywhere between QRS complexes, in which case an inverted P wave is seen in the inferior limb leads as seen in Fig. 244-2 where the inverted P wave is seen in the T wave. The rate can vary with sympathetic tone. Simultaneous atrial and ventricular contraction results in atrial contraction against a closed tricuspid valve producing cannon a wave visible in the jugular venous pulse often perceived as a fluttering sensation in the neck. Elevated venous pressures may also lead to release of natriuretic peptides that cause post-tachycardia diuresis. In contrast to ATs, maneuvers or medications that produce AV nodal block terminate the arrhythmia.

FIGURE 244-1

Atrioventricular (AV) node reentry. A. Leads II and V1 are shown. P waves are visible at the end of the QRS complex and are negative in lead II, and may give the impression ...

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