Dr.

Azadeh Mokhtari
Fellow ship of electrophysiology and pacemaker
Assistant Professor of Kerman University

 Common or typical right atrial flutter is due to a circuit
that revolves around the tricuspid valve annulus
bounded anteriorly by the annulus and posteriorly by
functional conduction block in the crista terminalis.
AVNRT
(A VNRT) is the most common form of PSVT
representing approximately 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.
ACCESSORY PATHWAYS AND THE WOLFF-
PARKINSON.WHITE SYN DROME

Accessory pathways (APs) occur in 1 in 1 500-2000

people and ar associated with a variety of
arrhythmias including narrow-complex PSVT
widecomplex tachycardias and rare sudden
death.
 APs are abnormal connections that allow conduction between
atrium and ventricles across the A V ring
. They are present from birth and are due to failure of complete
partitioning of atrium and ventricle by the fibrous A V rings.
They occur across either an A V valve annulus or the septum
most frequency between the left atrium and free wall of the left
ventricle followed by posteroseptal right free wall and
anteroseptal locations.
If the AP conducts from atrium to ventricle (ante grade) with a
shorter conduction time than the A V node and His bundle
then the ventricles are preexisted during sinus rhythm and the
ECG shows a short P-R interval (<0. 1 2 s) slurred initial
portion of the QRS (delta wave) and prolonged QRS duration
produced by slow conduction through direct activation of
ventricular myocardium over the AP
AVRT

AV Reentry Tachycardia The most common tachycardia caused by an

AP is the PSVT designated orthodromic A V reentry.
The circulating reentr wavefront propagates from the atrium
anterogradely over the A V node and His- Purkinje system to the
ventricles and then reenters the atria via retrograde conduction over
the AP

The QRS is narrow or may have typical right or left bundle branch
block but without preexcitation during tachycardia. Because
excitation through the normal A V conduction system and AP are
necessary A V or V Ablock results in tachycardia termination.

During sinus rhythm preexcitation is seen if the pathway also allows

anterograde conduction
Preexcited Tachycardias
Preexcitated tachycardia occurs when the ventricles are
activated by antegrade conduction over the AP .
The most common is antidromic A V reentry in which
activation propagates from atrium to ventricle via the AP
and then conducts retrogradel y to the atria via the His-
Purkinje system and the A V node (or rarely a second AP).
The wide QRS complex is produced entirely via ventricular
excitation over the AP because there is no contribution of
ventricular activation over more rapidly conducting
specialized His-Purkinje fibers.
This tachycardia is often indistinguishable from
monomorphicventricular tachycardia. The presence of
preexcitation in sinus rhythmsuggests the diagnosis.