Download Occurring During Cardiac Catheterization

Atrial Rhythm in Ventricular Tachyeardia
Occurring During Cardiac Catheterization
By A. D. KISTIN, M.D., A. TAWAKKOL, M.D.,
AND
R. A. MASSUMI, M.D.
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SUMMARY
The atrial rhythm was studied in 38 patients during runs of tachycardia of five or
more beats in sequence which occurred during cardiac catheterization and whose ventricular site of origin could be established with considerable confidence. Simultaneov-s
esophageal and other leads were recorded. The most frequent mechanism was retrograde conduction to the atria with varying degrees of V-A (ventriculo-atrial) block
which occurred in 26 of the 38 patients. Runs of ventricular tachycardia with one-toone V-A conduction occurred in 13 patients. Runs with an independent atrial
rhythm (A-V dissociation) occurred in nine patients. Varying atrial mechanisms during
different runs of tachyeardia occurred in 11 patients. The minimum QRS-to-retrograde
P intervals in 24 of 35 patients with V-A conduction were within 0.03 sec of P-R interval. The briefest QRS-to-retrograde P interval observed was 0.09 sec. Reciprocal
beats occurred in eight of 35 patients with V-A conduction.
ADDITIONAL INDEXING WORDS:
Atrio-ventricular dissociation
Reciprocal beating
Ventriculo-atrial (retrograde) conduction
Cardiac arrhythmia
beats in sequence) occurring during catheterization of the right and left ventricles were studied.
The position of the catheter tip during the tachycardia was verified in every run by the pressure
recorded through the catheter and often by fluoroscopic observation. The configuration of the
ectopic beats conformed with that expected from
premature ventricular beats originating within
the ventricle under observation. A large, wide S
or QS in lead V1 or a Z vector lead was observed with ectopic beats originating from the
right ventricle (figs. 1 and 2) and a large, wide,
usually notched R or an RSR' or QR in V, was observed with left ventricular ectopic beats (fig.
3). In two cases, ectopic beats which did not
conform with this pattern occurred when the
catheter was in the left ventricle and were excluded from the study.
Bipolar esophageal leads5 were recorded simultaneously with Frank vector leads8 or with
leads II and V1. The electrodes of the bipolar
lead were German silver rings, 3 mm wide,
mounted 2 cm apart on a soft rubber tube, 5 mm
in diameter. Multiple peripheral leads were recorded simultaneously with one or more esophageal leads in an attempt to reduce the error of
measurement of the QRS-to-retrograde P interval; the onset of activation may be recorded
better in some leads than in others.9 Some of
the records were obtained with an Electronics for
Medicine DR-8 photographic recorder. Others
AN independent atrial rhythm (A-V dissociation) is often considered characteristic
or diagnostic during ventricular tachycardia.'- Evidence, however, has been presented that retrograde conduction to the atria
occurs frequently.5 Since an unequivocal diagnosis of ventricular tachycardia is difficult,
if not impossible, in the usual clinical situation,6 7the problem was studied further during diagnostic cardiac catheterization under
conditions which establish the ventricular origin of spontaneous, catheter-induced tachycardia with reasonable assurance. The observations confirm the frequent occurrence of
retrograde conduction to the atria.
Methods
Runs of ventricular tachycardia (five or more
From the Cardiopulmonary Laboratory, Beckley
Appalachian Regional Hospital, Beckley, West Virginia, and the George Washington University Division of Medicine, District of Columbia General Hospital, Washington, District of Columbia.
Work supported in part by Grants HE-07578-03
and HE-07578-04 from the U. S. Public Health
Service.
10
Circulation, Volume XXXV, January 1967
ATRIAL RHYTHM
11
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Figure 1
Simnultaneous vector leads8 and a bipolar esophageal lead, 42 cm fromt the niares. Ventricular
tech ylcardia produced by a catheter in the right ventricle. Retrograde conduction to the atria
(PJ) icithi somie V-A block; 13 of the 1i9 ventricuilar beats are followed by V-A conductiont. At
the end of the run there is a venitricuilar reciprocal beat (R). The retrograde P wave preceding
this beat is visible niot onily in the esophageal lead but also as a small inverted deflection in the
Y lead.
II
p1
BE
Figure 2
Sirmultaneous leads II, V, andI a bipolar esophageal lead. Ventricular tachylcardia produced byI
a catheter in the right vtentricle. During the first beat of the run there is interference twith the
sinuts beat (P). After that every ventricular beat is followed by retrograde condluction to the
atria (P'). The average rate of the tachycardia is about 165 per mtinutte.
Circulazion, Volume XXXV, JanUary 1967
KISTIN ET AL.
12
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'I~~V~'1
V
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P1
h
N/AKNU>
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s
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Figure 3
a bipolar esophageal lead. Venitricular tachycardia produced
catheter in the left ventricle. Retrograde conduction to the atria (P) withl some V-A
block; 5 of the 7 vtietricu;lar beats are followved by V-A conduction.
Siniiiltanzeonis leads II, V/, alnd
byi
a
were obtained with
Sanborn-Ampex 2000 tape
recorder combined with a Sanborn 350 recorder
and played back on Sanborn 560 plhotographic
a
a
ecorder.
QRS-to-retrograde P intervals were imieasuLred
ven tricular tachycardia
who had retrograde conduction to the atria plus
six others with ventricutlar ectopic beats in runs
of less than five.
Parts of the data of this study were previotusly
eferr-ed to in discussions of esophageal leads'0
and the differential diagnosis of arrhythmias.
in those patients with
Observations
Ventricular tachycardia was studied during
cardiac catheterization in 38 patients, 36 with
normal A-V conduction and two with P-R
inttervals of 0.22 sec. In 18 of the patients
cardiac catheterization was done for evaluatioin of pulmonary hypertension in pulmonary
disease (Beckley group); these patients had
little or no clinical evidence of heart disease.
In 20 of the patients, the cardiac catheterization was for evaluation of significant heart disease (D. C. General Hospital group). Right
ventricular tachycardia alone occurred in 28
patients, left ventricular tachycardia alone in
five, and both right and left ventricular tachycardia in five. The most frequent mechanism
was retrograde conduction to the atria with
varying degrees of ventriculo-atrial (V-A)
block (figs. 1 and 3) which occurred in 26
patients. In 13 patients there were runs of 5
to 23 bcats, every one of which xvas followed
by V-A conduction (fig. 2). In nine patients
there were runs during xvhich none of the ventricular impulses were conducted retrograde,
and persistent A-V dissociation prevailed during ventricular tachycardia. In 11 patients
atrial mechanisms varied during different runs
Circulation, Volume XXXV, January 1967
13
ATRIAL RIIYTHM
x
y
.4
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iE
39
Figure 4
Simitultancous vector leads8 and a bipolar eso phageal lead, 39 cm from the nares. Durting the
first 5 beats of ventricular tachycardia at a rapid rate there is retrograde conduction to the
atria (P) three times. After that at a slower rate every ventricular beat is followed by retrograde conduiction. The ninith and fourteenth beats of the tacheyardliac occuir relativelyl early
after the preceding beats, and the followinig V-A condtuction times are prolonged.
of ventricular tachycardia. The incidences of
the various atrial mechanisms were about the
same with both right ventricular and left ventricular tachycardia, but the value of this 1)servation is limited by the small number of
cases of left ventricular tachycardia.
Whether or not retrograde conduction oc
curred seemed to depend sometimes on a
fortuitous timing relation of the tachycardiac
to the sinus rhythm and sometimes on the rate
of the tachycardia. It seemed clear in somne
runs where some beats were followed by V-A
conduction and some were not, that the la-tter
occurred at shorter intervals after preceding
beats and presumably encountered refractoriness of the conducting tissues (fig. 4). ln 27
patients it was possible to measure the intervals (R-R) between two successive beats both
of which were followed by V-A conduictions.
Intervals of 0.40 sec or less were observed in
all but two of the patients, of 0.30 sec or less
in 12 patients, of 0.22 sec in one, and of 0.18
sec in one. Examples of runs of ventricular
Circulation, Volume XXXV, January 1967
tachycardia at the fastest rates with one-toone V-A conduction are: 5 beats at an average
rate of 204 per minute; 10 beats, 189; 19
beats, 186; 12 beats, 180; 5 beats, 169; 11 beats,
165; 22 beats, 162; and 11 beats, 162.
In 35 patients with V-A conduction the
QRS-to-retrograde P intervals were measured
from the earliest deflection of QRS in any of
the simultaneous leads to the earliest deflection of the retrograde P wave and compared
wvith P-R (fig. 5). The minimum QRS-to-retrograde P interval in 24 of the 35 patients was
within 0.03 sec of the P-R. Some long QRS-toretrograde P intervals were observed as would
be expected after ectopic beats occurring early
in the cycle and during partial refractoriness
of the conducting tissues. The briefest QRS-toretrograde P interval observed was 0.09 sec.
Beats consistent with the interpretation of reciprocal rhythm" (fig. 1) in association with
V-A conduction were observed in eight of the
35 patients.
14
KISTIN ET AL.
2. RISEMAN, J. E. F., AND SAGALL, E. L.: Cardiac
RrP,
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0.01 sec
PR
Figure 5
Relation of the minimum QRS-to-retrograde P interval
(R-P') of ventricular ectopic beats to P-R in each
case. In 24 of the 35 cases R-P' is within 0.03 sec of
P-R (enclosed by the diagonal lines).
References
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Arrhythmias. New York, Macmillan Co., 1963.
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Circulation, Volume XXXV, January 1967
Atrial Rhythm in Ventricular Tachycardia Occurring During Cardiac
Catheterization
A. D. KISTIN, A. TAWAKKOL and R. A. MASSUMI
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Circulation. 1967;35:10-14
doi: 10.1161/01.CIR.35.1.10
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