Atrioventricular Node Reentrant

Tachycardia

Qathrun Nada, Muhammad Roby Al Qudry, Nadia Zuhra

Departemen/SMF Kardiologi
Fakultas Kedokteran Universitas Abulyatama
RSUD Meuraxa Banda Aceh
 Pendahuluan
PSVT adalah sindrom yang ditandai takikardia dan reguler dengan awitan serta terminasi tiba-tiba.
Gambaran ini dapat dengan karakter atrioventricular nodal reentrant tachycardia (AVNRT) atau
atrioventricular reentrant tachycardia (AVRT), dan yang sangat jarang atrial tachycardia (AT).

AVNRT AVRT AT

• 50-60% kasus PSVT • 30% kasus • 10% kasus

• Terjadi pada pasien diatas usia • Sering pada dekade 2 • Penyebab yang paling
20tahun (usia tua) kehidupan jarang pada PSVT

Page RL, Joglar JA, Caldwell MA, Calkins H, Conti JB, Deal BJ, et al. 2015 ACC/AHA/HRS Guideline for the management of adult patients with supraventricular tachycardia: A report of the American
College of Cardiology/American Heart Association Task Force on clinical practice guidelines and the Heart Rhythm Society. Circulation 2016;133;506-74.

Issa ZF, Miller JM, Zipes DP. Approach to paroxysmal supraventricular tachycardias In: Issa ZF, Miller JM, Zipes DP, editors. Clinical arrhythmology and electrophysiology: A companion to Braunwal
d’s heart disease. Philadelphia:Elsevier; 2012. pp. 480-98
Identitas Pasien

 Wanita, 85 tahun

 Pekerjaan: Ibu Rumah Tangga

 Tanggal masuk: 11 April 2021

 Dirawat di: ICCU

Anamnesis & Pemeriksaan Fisik
Pemeriksaan fisik
01 Anamnesis 02
• KU: baik; Kesadaran: CM
Kesulitan bernafas dirasakan sejak • TD: 123/87 mmHg; N: 141 x/m
3 hari SMRS disertai dengan batuk enit; RR: 26 x/menit, suhu 36.0
yang timbul sesekali. oC, SpO2 100%
• Nyeri dada tidak menjalar • S1 > S2 jantung
• Dada berdebar • Sianosis (-)
• Mual tetapi tidak muntah • KA (-)
• Demam disangkal • oedem kaki (-)
• BAK dan BAB dalam batas normal • asites (-)
• RPT: Hipertensi dan penyakit jant- • hepatosplenomegaly (-)
ung • JVP +2cm
• Ronkhi basa basal pada kedua
lapangan paru
• Akral hangat
 Laboratorium dan Elektrokardiografi
11 April 2021
Hemoglobin 11.3 g/dL
Hematokrit 33.5%
Leukosit 6.8 x 103/µL
Neutrofil 36.2%
Limfosit 51.8%
Monosit 6.5%
Ratio N/L 0.7
GDA 104 mg/dL
Ureum 22 mg/dL
Kreatinin 0.7 mg/dL
Natrium 142 mmol/L
Elektrokardiografi (11/04/2021)
Kalium 3.3 mmol/L
sesuai dengan SVT (SupraVentrikulet Takikardi), ST abnor
Klorida 107 mmol/L mal yang menandakan kemungkinan adanya infark suben
Rapid test antigen Covi Non reaktif docardial inferior, dengan kesan AVNRT Tipikal.
d-19
 DISKUSI
Takiaritmia dibagi menjadi dua kelompok
Aritmia adalah gangguan at besar, yaitu:
au abnormalitas penjalaran •Supraventricular Tachycardia (SVT)
impuls listrik ke miokardium • Ventricular Tachycardia (VT)

Paroxysmal SupraVentricular Tachycardia (PSVT) ad

alah sindrom klinis ditandai takikardia sangat cepat d
an reguler dengan awitan serta terminasi tiba-tiba.

AVNRT merupakan suatu gambaran klinis yang paling sering

terjadi dari Paroxysmal Supraventricular Tachycardia (PSVT)
Brugada P, Gursoy S, Brugada J, Andries E. Investigation of palpitations. Lancet. 1993;341:1254-8.

Page RL, Joglar JA, Caldwell MA, Calkins H, Conti JB, Deal BJ, et al. 2015 ACC/AHA/HRS Guideline for the management of adult patients with supraventricular tachycardia: A report of the American
College of Cardiology/American Heart Association Task Force on clinical practice guidelines and the Heart Rhythm Society. Circulation 2016;133;506-74.
 Etiologi & Klasifikasi
Amerika Serikat Secara Umum
36 per 100.000 2.29 per 1000
per tahun individu
Klasifikasi Atrioventricular Nodal Reentrant Tachycardia (AVRNT)
AH/HA VA (His) ERAA biasa
AVNRT Tipikal Slow-Fast >1 <60 m/s Rhis, CS os, Lhis
AVNRT Atipikal
Fast-slow <1 >60 m/s CS os, LRAS, Dcs
Slow-slow >1 >60 m/s CS os, dCS
AH = atrial – Intervalnya; CS os = ostium dari sinus koroner; dCS = sinus koroner distal; ERAA = aktivasi atrium retrograde paling
awal; HA = Interval atrium; LHis = Paket electrogram direkam dari septum kiri; LRAS = septum atrium kanan bawah; RHis = Elekto
gram bundel yang direkam dari septum kanan. Interval diukur dari permulaan aktivasi ventrikel (VA) pada EKG permukaan hingga
defleksi paling awal dari aktivasi atrium dalam electrogram bundel His

Olgin JE, Zipes DP. Supraventricular arrhythmias. In : Zipes DP, Libby P, Bonow RO, Mann DL, Tomaselli GF, editors. Braunwald’s heart disease a textbook of cardiovascular medicine 11th ed. Phila
delphia: Elsevier; 2019. pp.706-29
DG, Josephson ME. Classification, Electrophysiological Features and Therapy of Atrioventricular Nodal Reentrant Tachycardia. Arrhythm Electrophysiol Rev. 2016;5(2):130-135. doi:10.15420/AER.2
016.18.2.
 Jenis ANVRT berdasarkan presentasi EKG Diagnosa Banding

Gejala yang paling umum adalah palpitasi onset mendadak dan terminasi. Semakin cepat det
ak jantung, semakin tua usia pasien, palpitasi tidak dapat ditoleransi dengan baik, dan gejala
hipoperfusi lainnya mungkin muncul. Ciri palpitasi leher telah didalilkan sebagai satu-satunya
temuan klinis AVNRT ketika temuan pada EKG kurang.
Contreras-Valdes FM and Josephson ME (2016) Frog sign in atrioventricular nodal reentrant tachycardia. New England Journal of Medicine 374: e17.

Gonza´lez-Torrecilla E, Almendral J, Arenal A, et al. (2009) Combined evaluation of bedside clinical variables and the electrocardiogram for the differential diagnosis of paroxysmal atrioventricular reci
procating tachycardias in patients without pre-excitation. Journal of the American College of Cardiology 53: 2353–2358.
 Terapi AVNRT
Manajemen Manajemen
Akut Kronik
• Manuver • Ablasi
Valsava transkateter
• Agen • Obat antiaritmia
pemblokir AV
node
• Beta Blocker
IV
Page RL, Joglar JA, Caldwell MA, et al. (2015) ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia. Journal of the American College of Cardiology 67: e27–e115.
Glatter KA, Cheng J, Dorostkar P, et al. (1999) Electrophysiologic effects of adenosine in patients with supraventricular tachycardia. Circulation 99: 1034–1040.
 MANAJEMEN AKUT
Terminasi dengan agen Beta bloker IV:
Manuver valsava, pemblokir AV node:
Verapamil 10mg atau
ataupun pijat carotis / Adenosine 6mg → dosis
diltiazem 5-25mg
valsava ditingkatkan dengan
bolus bolus

Kasus resisten: Bolus adenosine + verapamil + diltiazem menghas

ilkan efektifitas yang lebih tinggi

Kasus AVNRT dengan hemodinamik tidak stabil:

Kardioversi sinkronisasi 10-15 J
Page RL, Joglar JA, Caldwell MA, et al. (2015) ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia. Journal of the American College of Cardiology 6
7: e27–e115.
Glatter KA, Cheng J, Dorostkar P, et al. (1999) Electrophysiologic effects of adenosine in patients with supraventricular tachycardia. Circulation 99: 1034–1040.
Reisinger J, Gstrein C, Winter T, et al. (2010) Optimization of initial energy for cardioversion of atrial tachyarrhythmias with biphasic shocks. American Journal of Emergency Medicine 28: 159–1
65.
 MANAJEMEN KRONIK
• Lini pertama
• Dulu, target terletak disekitar aspek
Ablasi anterosuperior di segitiga Koch =
Tingkat AV blok tinggi
Kateter • Target dipindahkan diantara ostium
sinus koronerdan annulus trikuspid

• Digoskin, verapamil, propanolol

• Jika kontraindikasi: flecainide atau
Obat anti propafenone
• Pasien dengan episode takikardi yang
aritmia jarang dan refrakter thd manuver
vagal: Pendekatan “pill in the pocket”

Mitrani RD, Klein LS, Hackett FK, Zipes DP, and Miles WM (1993) Radiofrequency ablation for atrioventricular node reentrant tachycardia: Compa
rison between fast (anterior) and slow (posterior) pathway ablation. Journal of the American College of Cardiology 21: 432–441.
Hsieh MH, Chen SA, Tai CT, et al. (1998) Absence of junctional rhythm during successful slow-pathway ablation in patients with atrioventricular no
dal reentrant tachycardia. Circulation 98: 2296–2300.
Winniford MD, Fulton KL, and Hillis LD (1984) Long-term therapy of paroxysmal supraventricular tachycardia: A randomized, double-blind compari
son of digoxin, propranolol and verapamil. American Journal of Cardiology 54: 1138–1139.
Ringkasan

01 Wanita, 85 tahun
Sulit bernafas, lemas, nyeri dada, ronkhi, suara jantung S1>S2.

Elektrokardiografi
02 sesuai dengan SVT (SupraVentrikulet Takikardi), ST abnormal yang menandakan
kemungkinan adanya infark subendocardial inferior, dengan kesan AVNRT Tipikal.

Progresivitas dan hasil akhir

03 Dirawat di ICCU, akhirnya pasien dapat rawat jalan karena perbaikan kondisi
 Daftar Pustaka
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3. Page RL, Joglar JA, Caldwell MA, Calkins H, Conti JB, Deal BJ, et al. 2015 ACC/AHA/HRS Guideline for the management of adult patients with supraventricul
ar tachycardia: A report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines and the Heart Rhythm Socie
ty. Circulation 2016;133;506-74.
4. Issa ZF, Miller JM, Zipes DP. Approach to paroxysmal supraventricular tachycardias In: Issa ZF, Miller JM, Zipes DP, editors. Clinical arrhythmology and electr
ophysiology: A companion to Braunwald’s heart disease. Philadelphia:Elsevier; 2012. pp. 480-98
5. Olgin JE, Zipes DP. Supraventricular arrhythmias. In : Zipes DP, Libby P, Bonow RO, Mann DL, Tomaselli GF, editors. Braunwald’s heart disease a textbook of
cardiovascular medicine 11th ed. Philadelphia: Elsevier; 2019. pp.706-29
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agnosis of paroxysmal atrioventricular reciprocating tachycardias in patients without pre-excitation. Journal of the American College of Cardiology 53: 2353–2358.
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 Daftar Pustaka
16. Page RL, Joglar JA, Caldwell MA, et al. (2015) ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia. Journal of th
e American College of Cardiology 67: e27–e115.
17. Glatter KA, Cheng J, Dorostkar P, et al. (1999) Electrophysiologic effects of adenosine in patients with supraventricular tachycardia. Circulation 99: 1034–10
40.
18. Reisinger J, Gstrein C, Winter T, et al. (2010) Optimization of initial energy for cardioversion of atrial tachyarrhythmias with biphasic shocks. American Journa
l of Emergency Medicine 28: 159–165.
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ean Heart Journal 17: 82–88.
21. Mitrani RD, Klein LS, Hackett FK, Zipes DP, and Miles WM (1993) Radiofrequency ablation for atrioventricular node reentrant tachycardia: Comparison betwe
en fast (anterior) and slow (posterior) pathway ablation. Journal of the American College of Cardiology 21: 432–441.
22. Hsieh MH, Chen SA, Tai CT, et al. (1998) Absence of junctional rhythm during successful slow-pathway ablation in patients with atrioventricular nodal reentra
nt tachycardia. Circulation 98: 2296–2300.
23. Winniford MD, Fulton KL, and Hillis LD (1984) Long-term therapy of paroxysmal supraventricular tachycardia: A randomized, double-blind comparison of digo
xin, propranolol and verapamil. American Journal of Cardiology 54: 1138–1139.
24. Yeh SJ, Lin FC, Chou YY, et al. (1985) Termination of paroxysmal supraventricular tachycardia with a single oral dose of diltiazem and propranolol. Circulatio
n 71: 104–109.
Terima Kasih