Clinical Ablation| Volume 16, ISSUE 5, P717-723, May 2019

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A novel pacing maneuver to verify the postpacing interval minus the tachycardia cycle length while adjusting for decremental conduction: Using “dual-chamber entrainment” for improved supraventricular tachycardia discrimination

Published:November 19, 2018DOI:


      The postpacing interval (PPI) minus the tachycardia cycle length (TCL) is frequently used to investigate tachycardias. However, a variety of issues (eg, failure to entrain, decremental conduction, and oscillating TCLs) can make interpretation of the PPI–TCL challenging.


      The purpose of this study was to investigate a novel maneuver to confirm the PPI–TCL value without using either the ventricular PPI or the TCL interval and to assess the ability of this maneuver to identify decremental conduction and differentiate supraventricular tachycardias.


      We analyzed 77 intracardiac recordings from patients (age 25 ± 20 years; 40 female) who underwent catheter ablation of atrioventricular nodal reentrant tachycardia (AVNRT) or orthodromic reciprocating tachycardia (ORT) with a concealed pathway. We calculated the PPI–TCL, the AH-corrected PPI–TCL, and estimated the PPI–TCL using “dual-chamber entrainment” calculated as [PPIV – TCL = Stim(A→V) + Stim(V→A) – PPIA].


      The PPI–TCL calculated by dual-chamber entrainment highly correlated with the observed and AH-corrected PPI–TCL (R2 = 0.79 and 0.96, respectively; P <.001]. A dual-chamber entrainment PPI–TCL value of 80 ms correctly differentiated all AVNRT from septal ORT cases, whereas the standard PPI–TCL and AH-corrected PPI–TCL methods were incorrect in 14% and 6% of cases, respectively. Dual-chamber entrainment identified 3 ± 10 ms of additional decremental conduction beyond AH prolongation, including 4 pathways with significant (>10 ms) decrement.


      Dual-chamber entrainment estimates the PPI–TCL value without using either the ventricular PPI or the TCL interval. This maneuver adjusts for all decremental conduction, including within concealed pathways, where a dual-chamber entrainment PPI–TCL value >80 ms favors AVNRT over ORT. This maneuver can be used to verify the observed PPI–TCL value in challenging cases.

      Graphical abstract


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        • Boonyapisit W.
        • Methavigul K.
        • Krittayaphong R.
        • Sriratanasathavorn C.
        • Pumprueg S.
        • Suwanagool A.
        • Winijkul A.
        • Jongnarangsin K.
        Determining the site of accessory pathways in orthodromic reciprocating tachycardia by using the response to right ventricular pacing.
        Pacing Clin Electrophysiol. 2016; 39: 115-121
        • 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
        • Blömstrom-Lundqvist C.
        • Scheinman M.M.
        • Aliot E.M.
        • et al.
        ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias—executive summary. A report of the American college of cardiology/American heart association task force on practice guidelines and the European society of cardiology.
        Eur Heart J. 2003; 42: 1857-1897
        • Stevenson W.G.
        • Khan H.
        • Sager P.
        • Saxon L.A.
        • Middlekauff H.R.
        • Natterson P.D.
        • Wiener I.
        Identification of reentry circuit sites during catheter mapping and radiofrequency ablation of ventricular tachycardia late after myocardial infarction.
        Circulation. 1993; 88: 1647-1670
        • Katritsis D.G.
        • Boriani G.
        • Cosio F.G.
        • et al.
        European Heart Rhythm Association (EHRA) consensus document on the management of supraventricular arrhythmias, endorsed by Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulacion Cardiaca y Elect.
        Europace. 2017; 19: 465-511
        • Tung R.
        Challenges and pitfalls of entrainment mapping of ventricular tachycardia: ten illustrative concepts.
        Circ Arrhythm Electrophysiol. 2017; 10: e004560
        • Murdock C.J.
        • Leitch J.W.
        • Teo W.S.
        • Sharma A.D.
        • Yee R.
        • Klein G.J.
        Characteristics of accessory pathways exhibiting decremental conduction.
        Am J Cardiol. 1991; 67: 506-510
        • Brugada P.
        • Bar F.W.
        • Vanagt E.J.
        • Friedman P.L.
        • Wellens H.J.
        Observations in patients showing A-V junctional echoes with a shorter P-R than R-P interval.
        Am J Cardiol. 1981; 48: 611-622
        • Gonzalez-Torrecilla E.
        • Arenal A.
        • Atienza F.
        • Osca J.
        • Garcia-Fernandez J.
        • Puchol A.
        • Sanchez 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
        • Waldecker B.
        • Coromilas J.
        • Saltman A.E.
        • Dillon S.M.
        • Wit A.L.
        Overdrive stimulation of functional reentrant circuits causing ventricular tachycardia in the infarcted canine heart. Resetting and entrainment.
        Circulation. 1993; 87: 1286-1305
        • Schoels W.
        • Restivo M.
        • Caref E.B.
        • Gough W.B.
        • el-Sherif N.
        Circus movement atrial flutter in canine sterile pericarditis model. Activation patterns during entrainment and termination of single-loop reentry in vivo.
        Circulation. 1991; 83: 1716-1730
        • Stevenson W.G.
        • Friedman P.L.
        • Sager P.T.
        • Saxon L.A.
        • Kocovic D.
        • Harada T.
        • Wiener I.
        • Khan H.
        Exploring postinfarction reentrant ventricular tachycardia with entrainment mapping.
        J Am Coll Cardiol. 1997; 29: 1180-1189
        • Issa Z.F.
        • Miller J.M.
        • Zipes D.P.
        Post-infarction sustained monomorphic ventricular tachycardia.
        in: Clinical Arrhythmology and Electrophysiology: A Companion to Braunwald’s Heart Disease. 2nd ed. WB Saunders, Philadelphia2012: 512-561
        • Huang S.K.
        • Wood M.A.
        Catheter Ablation of Cardiac Arrhythmias.
        2nd ed. Elsevier Inc, Philadelphia2011
        • Kaiser D.W.
        • Hsia H.H.
        • Dubin A.M.
        • Liem L.B.
        • Viswanathan M.N.
        • Zei P.C.
        • Wang P.J.
        • Narayan S.M.
        • Turakhia M.P.
        The precise timing of tachycardia entrainment is determined by the postpacing interval, the tachycardia cycle length, and the pacing rate: theoretical insights and practical applications.
        Heart Rhythm. 2016; 13: 695-703
        • Chen S.A.
        • Tai C.T.
        • Chiang C.E.
        • Lee S.H.
        • Wen Z.C.
        • Chiou C.W.
        • Ueng K.C.
        • Chen Y.J.
        • Yu W.C.
        • Huang J.L.
        • Chang M.S.
        Electrophysiologic characteristics, electropharmacologic responses and radiofrequency ablation in patients with decremental accessory pathway.
        J Am Coll Cardiol. 1996; 28: 732-737
        • Perez-Rodon J.
        • Bazan V.
        • Bruguera-Cortada J.
        • Mojal-Garcia S.
        • Manresa-Dominguez J.M.
        • Marti-Almor J.
        Entrainment from the para-Hisian region for differentiating atrioventricular node reentrant tachycardia from orthodromic atrioventricular reentrant tachycardia.
        Europace. 2008; 10: 1205-1211
        • Steinberg J.S.
        • Jaïs P.
        • Calkins H.
        Practical Guide to Catheter Ablation of Atrial Fibrillation.
        John Wiley & Sons, Chichester, UK2015
        • Callans D.J.
        • Hook B.G.
        • Josephson M.E.
        Comparison of resetting and entrainment of uniform sustained ventricular tachycardia. Further insights into the characteristics of the excitable gap.
        Circulation. 1993; 87: 1229-1238