We would like to make a few comments on the interesting observations made by Drs. Michaud and Morady. First, in our opinion, an easier detection of clear entrainment is obtained with a pacing cycle length 20 to 40 ms shorter than the TCL. In addition, based on our experience from 22 consecutive patients with atypical AVNRT and 36 consecutive patients with ORT through a septal concealed accessory pathway, a PPI-TCL difference <115 ms without correction for AV nodal delay would result in a decrease of sensitivity for the diagnosis of the latter tachycardia mechanism (78% vs 100% with the appropriate correction; Figure 1). Therefore, the corrected PPI-TCL interval permits the correct diagnosis of septal ORT using a single parameter. Second, this simple maneuver would also rule out an atrial tachycardia in patients with typical AVNRT if a V-A-V response is observed after ventricular entrainment. Third, the technique is proposed as a simple, initial maneuver through which a free-wall accessory pathway could be suggested using only two right-sided catheters, thus avoiding the initial placement of a catheter in the coronary sinus after induction of a long VA interval tachycardia. In fact, according to our experience, even the highest corrected PPI-TCL value in ORT patients was out of the range of values we observed in atypical AVNRT patients (135 ms). We greatly appreciate the seminal contribution and the interest in our article shown by Drs. Michaud and Morady.
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Published online: August 10, 2006
© 2006 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.
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- To the EditorHeart RhythmVol. 3Issue 9
- PreviewWe read with great interest the article by González-Torrecilla et al1 in the June 2006 issue of Heart Rhythm. This is an excellent refinement of the postpacing interval—tachycardia cycle length (PPI-TCL) and stimulus-atrial—ventriculoatrial (SA-VA) criteria we first proposed for differentiating septal orthodromic reciprocating tachycardia (ORT) from atypical atrioventricular nodal reentrant tachycardia (AVNRT).2 We would like to make a few comments. First, the authors report 5of 31 patients with septal ORT who had a PPI-TCL >115 ms (our original criteria), but they used right ventricular (RV) pacing cycle lengths 20 to 40 ms below the TCL.