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Differential diagnosis of regular, narrow-QRS tachycardias

      We present an update on clinical and electrophysiological criteria used for the differential diagnosis of regular supraventricular tachycardias. Although several electrocardiographic clues may assist in the differential diagnosis, this is usually accomplished at electrophysiology study, and most often, the differential diagnosis is between atrioventricular nodal reentrant tachycardia, atrioventricular reentrant tachycardia due to a concealed accessory pathway, and atrial tachycardia. Atrial and ventricular pacing maneuvers during sinus rhythm or tachycardia have been used with various success rates. In clinical practice, these techniques cannot be applied to all cases, and multiple criteria must be used for the differential diagnosis of narrow-complex tachycardias with atypical characteristics.

      Abbreviations:

      AVNRT (atrioventricular nodal reentrant tachycardia), AVRT (atrioventricular reentrant tachycardia), CL (cycle length), JT (junctional tachycardia), PPI (postpacing interval), RBBB (right bundle branch block), RV (right ventricular), SVT (supraventricular tachycardia), TCL (tachycardia cycle length)

      Keywords

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      References

        • Katritsis D.G.
        • Gersh B.J.
        • Camm A.J.
        Clinical Cardiology: Current Practice Guidelines.
        Oxford University Press, Oxford, England2013
        • Orejarena L.A.
        • Vidaillet Jr, H.
        • DeStefano F.
        • Nordstrom D.L.
        • Vierkant R.A.
        • Smith P.N.
        • Hayes J.J.
        Paroxysmal supraventricular tachycardia in the general population.
        J Am Coll Cardiol. 1998; 31: 150-157
        • Porter M.J.
        • Morton J.B.
        • Denman R.
        • Lin A.C.
        • Tierney S.
        • Santucci P.A.
        • Cai J.J.
        • Madsen N.
        • Wilber D.J.
        Influence of age and gender on the mechanism of supraventricular tachycardia.
        Heart Rhythm. 2004; 1: 393-396
        • Katritsis D.G.
        • Camm A.J.
        Classification and differential diagnosis of atrioventricular nodal re-entrant tachycardia.
        Europace. 2006; 8: 29-36
        • Katritsis D.G.
        • Josephson M.E.
        Classification of electrophysiological types of atrioventricular nodal re-entrant tachycardia: a reappraisal.
        Europace. 2013; 15: 1231-1240
      1. Katritsis DG, Sepahpour A, Marine JE, Katritsis GD, Tanawuttiwat T, Calkins H, Rowland E, Josephson ME. Atypical atrioventricular nodal reentrant tachycardia: prevalence, electrophysiologic characteristics, and tachycardia circuit [published online ahead of print February 1, 2015]. Europace pii: euu387.

        • Kalbfleisch S.J.
        • el-Atassi R.
        • Calkins H.
        • Langberg J.J.
        • Morady F.
        Differentiation of paroxysmal narrow QRS complex tachycardias using the 12-lead electrocardiogram.
        J Am Coll Cardiol. 1993; 21: 85-89
        • Tai C.T.
        • Chen S.A.
        • Chiang C.E.
        • Lee S.H.
        • Wen Z.C.
        • Chiou C.W.
        • Ueng K.C.
        • Chen Y.J.
        • Yu W.C.
        • Chang M.S.
        A new electrocardiographic algorithm using retrograde P waves for differentiating atrioventricular node reentrant tachycardia from atrioventricular reciprocating tachycardia mediated by concealed accessory pathway.
        J Am Coll Cardiol. 1997; 29: 394-402
        • Di Toro D.
        • Hadid C.
        • López C.
        • Fuselli J.
        • Luis V.
        • Labadet C.
        Utility of the aVL lead in the electrocardiographic diagnosis of atrioventricular node re-entrant tachycardia.
        Europace. 2009; 11: 944-948
        • Haghjoo M.
        • Bahramali E.
        • Sharifkazemi M.
        • Shahrzad S.
        • Peighambari M.
        Value of the aVR lead in differential diagnosis of atrioventricular nodal reentrant tachycardia.
        Europace. 2012; 14: 1624-1628
        • Crawford T.C.
        • Mukerji S.
        • Good E.
        • Chugh A.
        • Bogun F.
        • Pelosi Jr, F.
        • Oral H.
        • Morady F.
        • Jongnarangsin K.
        Utility of atrial and ventricular cycle length variability in determining the mechanism of paroxysmal supraventricular tachycardia.
        J Cardiovasc Electrophysiol. 2007; 18: 698-703
        • Yamabe H.
        • Tanaka Y.
        • Morihisa K.
        • Uemura T.
        • Enomoto K.
        • Kawano H.
        • Ogawa H.
        Analysis of the anatomical tachycardia circuit in verapamil-sensitive atrial tachycardia originating from the vicinity of the atrioventricular node.
        Circ Arrhythm Electrophysiol. 2010; 3: 54-62
        • Katritsis D.G.
        • Ellenbogen K.A.
        • Becker A.E.
        Atrial activation during atrioventricular nodal reentrant tachycardia: studies on retrograde fast pathway conduction.
        Heart Rhythm. 2006; 3: 993-1000
        • Katritsis D.
        • Ellenbogen K.
        • Becker A.
        • Camm A.J.
        Retrograde slow pathway conduction in patients with atrioventricular nodal reentrant tachycardia.
        Europace. 2007; 9: 458-465
        • Crozier I.
        • Wafa S.
        • Ward D.
        • Camm J.
        Diagnostic value of comparison of ventriculoatrial interval during junctional tachycardia and right ventricular apical pacing.
        Pacing Clin Electrophysiol. 1989; 12: 942-953
        • Tai C.T.
        • Chen S.A.
        • Chiang C.E.
        • Chang M.S.
        Characteristics and radiofrequency catheter ablation of septal accessory atrioventricular pathways.
        Pacing Clin Electrophysiol. 1999; 22: 500-511
        • Martinez-Alday J.D.
        • Almendral J.
        • Arenal A.
        • Ormaetxe J.M.
        • Pastor A.
        • Villacastin J.P.
        • Medina O.
        • Peinado R.
        • Delcan J.L.
        Identification of concealed posteroseptal Kent pathways by comparison of ventriculoatrial intervals from apical and posterobasal right ventricular sites.
        Circulation. 1994; 89: 1060-1067
        • Horowitz L.N.
        • Alexander J.A.
        • Edmunds Jr, L.H.
        Postoperative right bundle branch block: identification of three levels of block.
        Circulation. 1980; 62: 319-328
        • Miller J.M.
        • Rosenthal M.E.
        • Gottlieb C.D.
        • Vassalo J.A.
        • Josephson M.E.
        Usefulness of the ΔHA interval to accurately distinguish atrioventricular nodal reentry from orthodromic septal bypass tract tachycardias.
        Am J Cardiol. 1991; 68: 1037-1044
        • Owada S.
        • Iwasa A.
        • Sasaki S.
        • Higuma T.
        • Kimura M.
        • Kobayashi T.
        • Ashikaga K.
        • Okumura K.
        “V-H-A pattern” as a criterion for the differential diagnosis of atypical AV nodal reentrant tachycardia from AV reciprocating tachycardia.
        Pacing Clin Electrophysiol. 2005; 28: 667-674
        • Srivathsan K.
        • Gami A.S.
        • Barrett R.
        • Monahan K.
        • Packer D.L.
        • Asirvatham S.J.
        Differentiating atrioventricular nodal reentrant tachycardia from junctional tachycardia: novel application of the delta H-A interval.
        J Cardiovasc Electrophysiol. 2008; 19: 1-6
        • Hirao K.
        • Otomo K.
        • Wang X.
        • Beckman K.J.
        • McClelland J.H.
        • Widman L.
        • Gonzalez M.D.
        • Arruda M.
        • Nakagawa H.
        • Lazzara R.
        • Jackman W.M.
        Para-Hisian pacing: a new method for differentiating retrograde conduction over an accessory AV pathway from conduction over the AV node.
        Circulation. 1996; 94: 1027-1035
        • Kapa S.
        • Henz B.D.
        • Dib C.
        • Cha Y.M.
        • Friedman P.A.
        • Munger T.M.
        • Ladewig D.J.
        • Hammill S.C.
        • Packer D.L.
        • Asirvatham S.J.
        Utilization of retrograde right bundle branch block to differentiate atrioventricular nodal from accessory pathway conduction.
        J Cardiovasc Electrophysiol. 2009; 20: 751-758
        • Obeyesekere M.
        • Gula L.J.
        • Modi S.
        • Leong-Sit P.
        • Angaran P.
        • Mechulan A.
        • Skanes A.C.
        • Krahn A.D.
        • Yee R.
        • Klein G.J.
        Tachycardia induction with ventricular extrastimuli differentiates atypical atrioventricular nodal reentrant tachycardia from orthodromic reciprocating tachycardia.
        Heart Rhythm. 2012; 9: 335-341
        • Kadish A.H.
        • Morady F.
        The response of paroxysmal supraventricular tachycardia to overdrive atrial and ventricular pacing: can it help determine the tachycardia mechanism?.
        J Cardiovasc Electrophysiol. 1993; 4: 239-252
        • Katritsis D.G.
        • Becker A.E.
        • Ellenbogen K.A.
        • Giazitzoglou E.
        • Korovesis S.
        • Camm A.J.
        Effect of slow pathway ablation in atrioventricular nodal reentrant tachycardia on the electrophysiologic characteristics of the inferior atrial inputs to the human atrioventricular node.
        Am J Cardiol. 2006; 97: 860-865
        • Miles W.M.
        • Yee R.
        • Klein G.J.
        • Zipes D.P.
        • Prystowsky E.N.
        The preexcitation index: an aid in determining the mechanism of supraventricular tachycardia and localizing accessory pathways.
        Circulation. 1986; 74: 493-500
        • Yamashita T.
        • Inoue H.
        • Nozaki A.
        • Kuo T.T.
        • Usui M.
        • Saihara S.
        • Sugimoto T.
        A new method for estimating preexcitation index without extrastimulus technique and its usefulness in determining the mechanism of supraventricular tachycardia.
        Am J Cardiol. 1991; 67: 830-834
        • Knight B.P.
        • Zivin A.
        • Souza J.
        • Flemming M.
        • Pelosi F.
        • Goyal R.
        • Man C.
        • Strickberger S.A.
        • Morady F.
        A technique for the rapid diagnosis of atrial tachycardia in the electrophysiology laboratory.
        J Am Coll Cardiol. 1999; 33: 775-781
        • Vijayaraman P.
        • Kok L.C.
        • Rhee B.
        • Ellenbogen K.A.
        Wide complex tachycardia: what is the mechanism?.
        Heart Rhythm. 2005; 2: 107-109
        • Crawford T.C.
        • Morady F.
        • Pelosi Jr, F.
        A long R-P paroxysmal supraventricular tachycardia: what is the mechanism?.
        Heart Rhythm. 2007; 4: 1364-1365
        • Kalra D.
        • Morady F.
        Supraventricular tachycardia: what is the mechanism?.
        Heart Rhythm. 2008; 5: 1219-1220
        • Ormaetxe J.M.
        • Almendral J.
        • Arenal A.
        • Martinez-Alday J.D.
        • Pastor A.
        • Villacastin J.P.
        • Delcán J.L.
        Ventricular fusion during resetting and entrainment of orthodromic supraventricular tachycardia involving septal accessory pathways: implications for the differential diagnosis with atrioventricular nodal reentry.
        Circulation. 1993; 88: 2623-2631
        • Nagashima K.
        • Kumar S.
        • Stevenson W.G.
        • Epstein L.M.
        • John R.M.
        • Tedrow U.B.
        • Koplan B.A.
        • Michaud G.F.
        Antegrade conduction to the His bundle during right ventricular overdrive pacing distinguishes septal pathway atrioventricular reentry from atypical atrioventricular nodal reentrant tachycardia.
        Heart Rhythm. 2015; 12: 735-743
        • AlMahameed S.T.
        • Buxton A.E.
        • Michaud G.F.
        New criteria during right ventricular pacing to determine the mechanism of supraventricular tachycardia.
        Circ Arrhythm Electrophysiol. 2010; 3: 578-584
        • Dandamudi G.
        • Mokabberi R.
        • Assal C.
        • Das M.K.
        • Oren J.
        • Storm R.
        • Vijayaraman P.
        • Miller J.M.
        A novel approach to differentiating orthodromic reciprocating tachycardia from atrioventricular nodal reentrant tachycardia.
        Heart Rhythm. 2010; 7: 1326-1329
        • Rosman J.Z.
        • John R.M.
        • Stevenson W.G.
        • Epstein L.M.
        • Tedrow U.B.
        • Koplan B.A.
        • Albert C.M.
        • Michaud G.F.
        Resetting criteria during ventricular overdrive pacing successfully differentiate orthodromic reentrant tachycardia from atrioventricular nodal reentrant tachycardia despite interobserver disagreement concerning QRS fusion.
        Heart Rhythm. 2011; 8: 2-7
        • Michaud G.F.
        • Tada H.
        • Chough S.
        • Baker R.
        • Wasmer K.
        • Sticherling C.
        • Oral H.
        • Pelosi Jr, F.
        • Knight B.P.
        • Strickberger S.A.
        • Morady F.
        Differentiation of atypical atrioventricular node re-entrant tachycardia from orthodromic reciprocating tachycardia using a septal accessory pathway by the response to ventricular pacing.
        J Am Coll Cardiol. 2001; 38: 1163-1167
        • González-Torrecilla E.
        • Arenal A.
        • Atienza F.
        • Osca J.
        • García-Fernández J.
        • Puchol A.
        • Sánchez A.
        • Almendral J.
        First postpacing interval after tachycardia entrainment with correction for atrioventricular node delay: a simple maneuver for differential diagnosis of atrioventricular nodal reentrant tachycardias versus orthodromic reciprocating tachycardias.
        Heart Rhythm. 2006; 3: 674-679
        • Bennett M.T.
        • Leong-Sit P.
        • Gula L.J.
        • Skanes A.C.
        • Yee R.
        • Krahn A.D.
        • Hogg E.C.
        • Klein G.J.
        Entrainment for distinguishing atypical atrioventricular node reentrant tachycardia from atrioventricular reentrant tachycardia over septal accessory pathways with long-RP tachycardia [published correction appears in Circ Arrhythm Electrophysiol 2011;4:e69].
        Circ Arrhythm Electrophysiol. 2011; 4: 506-509
        • Veenhuyzen G.D.
        • Coverett K.
        • Quinn F.R.
        • Sapp J.L.
        • Gillis A.M.
        • Sheldon R.
        • Exner D.V.
        • Mitchell L.B.
        Single diagnostic pacing maneuver for supraventricular tachycardia.
        Heart Rhythm. 2008; 5: 1152-1158
        • Segal O.R.
        • Gula L.J.
        • Skanes A.C.
        • Krahn A.D.
        • Yee R.
        • Klein G.J.
        Differential ventricular entrainment: a maneuver to differentiate AV node reentrant tachycardia from orthodromic reciprocating tachycardia.
        Heart Rhythm. 2009; 6: 493-500
        • Ho R.T.
        • Mark G.E.
        • Rhim E.S.
        • Pavri B.B.
        • Greenspon A.J.
        Differentiating atrioventricular nodal reentrant tachycardia from atrioventricular reentrant tachycardia by ΔHA values during entrainment from the ventricle.
        Heart Rhythm. 2008; 5: 83-88
        • Reddy V.Y.
        • Jongnarangsin K.
        • Albert C.M.
        • Sabbour H.
        • Keane D.
        • Mela T.
        • McGovern B.
        • Ruskin J.N.
        Para-Hisian entrainment: a novel pacing maneuver to differentiate orthodromic atrioventricular reentrant tachycardia from atrioventricular nodal re-entrant tachycardia.
        J Cardiovasc Electrophysiol. 2003; 14: 1321-1328
        • Pérez-Rodon J.
        • Bazan V.
        • Bruguera-Cortada J.
        • Mojal-García S.
        • Manresa-Domínguez J.M.
        • Martí-Almor J.
        Entrainment from the para-Hisian region for differentiating atrioventricular node reentrant tachycardia from orthodromic atrioventricular reentrant tachycardia.
        Europace. 2008; 10: 1205-1211
        • Singh D.K.
        • Viswanathan M.N.
        • Tanel R.E.
        • et al.
        His overdrive pacing during supraventricular tachycardia: a novel maneuver for distinguishing atrioventricular nodal reentrant tachycardia from atrioventricular reciprocating tachycardia.
        Heart Rhythm. 2014; 11: 1327-1335
        • Man K.C.
        • Niebauer M.
        • Daoud E.
        • Strickberger S.A.
        • Kou W.
        • Williamson B.D.
        • Morady F.
        Comparison of atrial-His intervals during tachycardia and atrial pacing in patients with long RP tachycardia.
        J Cardiovasc Electrophysiol. 1995; 6: 700-710
        • Sarkozy A.
        • Richter S.
        • Chierchia G.B.
        • De Asmundis C.
        • Seferlis C.
        • Brugada P.
        • Kaufman L.
        • Buyl R.
        • Dorian P.
        • Mangat I.
        A novel pacing manoeuvre to diagnose atrial tachycardia.
        Europace. 2008; 10: 459-466
        • Padanilam B.J.
        • Manfredi J.A.
        • Steinberg L.A.
        • Olson J.A.
        • Fogel R.I.
        • Prystowsky E.N.
        Differentiating junctional tachycardia and atrioventricular node re-entry tachycardia based on response to atrial extrastimulus pacing.
        J Am Coll Cardiol. 2008; 52: 1711-1717
        • Chen H.
        • Shehata M.
        • Cingolani E.
        • Chugh S.S.
        • Chen M.
        • Wang X.
        Differentiating atrioventricular nodal re-entrant tachycardia from junctional tachycardia: conflicting responses?.
        Circ Arrhythm Electrophysiol. 2015; 8: 232-235
        • Fan R.
        • Tardos J.G.
        • Almasry I.
        • Barbera S.
        • Rashba E.J.
        • Iwai S.
        Novel use of atrial overdrive pacing to rapidly differentiate junctional tachycardia from atrioventricular nodal reentrant tachycardia.
        Heart Rhythm. 2011; 8: 840-844

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        Heart RhythmVol. 13Issue 2
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          In the article titled “Differential diagnosis of regular, narrow-QRS tachycardias” by Demosthenes G.Katritsis, MD, PhD, Mark E. Josephson, MD, that was published in the July 2015 issue of HeartRhythm (Heart Rhythm2015;12:1667–1676), the references in Table 2 were inaccurate. Table 2 is printed below with the correct reference citations.
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