2. What make the complex narrow ?
1- The impulse originates above the
ventricles
2- The impulse conducts to the ventricle
centrally (through the AVN-His)
3- The LBB and RBB are intact
(Simultaneous LV and RV activation)
3. What make the complex wide ?
1- The impulse originates from the
ventricles
2- The impulse conducts to the ventricle
eccentrically (through acces pathway)
3- LBBB or RBBB
4. Wide complex tachycardias
1- PVCs
2- Ventricular tachycardia
3- Antidromic AVRT
4- SVT with BBB
5- AF or flutter with antegrade
accessory pathway conduction
6- AF or flutter with BBB
7- PM mediated tachycardia
14. Morphologic criteria
Initial R
more than
40ms
In the presence of LBBB like morphology
Capture beats
Fusion beats
Notch Any Q in V6
Rapid
downstroke
No q
LBBB
aberration
16. Ultrasimple Brugada criterion:
RW to peak Time (RWPT)
Sensitivity 60%, specificity 82.7%.
Pava LF, Perafán P, Badiel M, Arango JJ, Mont L, Morillo CA, and Brugada J. R-wave peak time at DII: a new criterion for differentiating
between wide complex QRS tachycardias. Heart Rhythm 2010 Jul; 7(7) 922-6. doi:10.1016/j.hrthm.2010.03.001 pmid:20215043
17. Individuals with previous MI or known CAD are
approximately 4 times more likely to present with VT
rather than SVT etiologies of their WCT
80% of all patients presenting with WCT will be
diagnosed having VT as the cause of WCT
Wide QRS complex tachycardia: ECG differential diagnosis.Brady WJ, Skiles J. Am J Emerg Med. 1999 Jul; 17(4):376-81.
18. History of prior MI, CHF, and recent angina all had
positive predictive values for VT greater than 95%
The best predictor for SVT was age less than or
equal to 35 years (positive predictive value of 70%)
Hemodynamic instability favors VT
Irregular cannon waves favors VT
Variability of S1 and SBP favors VT
Vagal maneuvers may reveal SVT
In pt with a PM, a magnet can terminate PMT
19. Different axis in limb leads indicates VT
Preexisting BBB
WPW
P wave morphology helps recognize AV
dissociation
IVCD
Prior MI
21. VT due to Enhanced Automaticity
General features
-Gradual onset and offset
-Can not be terminated by DC shocks
-Secondary to a causes (hypoxia, ischemia, sympathomimetic
drugs, thyrotoxicosis, electrolyte disturbance, HF, PE)
-May be idiopathic (idiopathic VT)
22. General Management
Treat the cause
If symptomatic:
-B blockers, Calcium channel blockers
-Xylocaine, mexiletine, amiodarone
-Ablation
VT due to Enhanced Automaticity
23. General Features
-Sudden onset & offset
-Fixed rate
-Can be induced by programmed extrastimulation
-Can be terminated by overdrive pacing (ATP)
-Can be terminated by DC shock
Reentrant VT
(scar related VT)
39. • Congenital Long QT Syndrome
• Acquired Long QT Syndrome
• Short QT Syndrome
• Brugada Syndrome
• Catecholaminergic Polymorphic VT
• Early repolarization syndrome
VT due to Channelopathies
40. VT
Idiopathic VT Scar related VT
Normal heart
10% of all VTs
Young, middle aged
Automatic / triggered
Commonly from outflow tracts
(adenosine sensitive)
Respond to BB, CCB
Ablation is curativs
Structural heart disease
Elderly, middle aged
Reentrant
Respond to BB, amiodarone
ICD
3D guided ablation can decrease
shocks from ICD (40%)
41. The most frequently (70%) idiopathic ventricular
arrhythmias originate from the right ventricular outflow
tract (RVOT) multiple extrasystoles, couplets, and
even short bouts of ventriculartachycardia.
Recent reports described theoccurrence of
cardiomyopathy associated with RVOT ectopic activity
Idiopathic VT
42. Idiopathic dilated cardiomyopathy rarely is associated
with extrasystoles having a pattern of left bundle branch
block with normal or inferior axis, suggesting that RVOT
extrasystoles are unlikely a consequence of
cardiomyopathy.
More importantly,in all these reports, a dramatic
improvement of LV function occurred after RFA of
ventricular ectopy, suggesting that the cardiomyopathy
actually resulted from the ventricular arrhythmia
Idiopathic VT
43.
44. V5
V6
LVOT-VT:
Supravalvular focus: Absent S in V5, V6
Infravalvular focus: S in V5, V6
Sensitivity 100%
Specificity 88%
Hachiya H, et al. . How to diagnose, locate, and ablate coronary cusp ventricular tachycardia. J Cardiovasc
Electrophysiol 2002;13:551-6.
46. 1- Area of conduction
block:
Scar area + MVA
2- Surviving myocardial
strands within the scar
(isthmus)
3- An outer loop of normal
myocardioum
4- Entrance
5- Exit
Components of VT reentry circuit
Non viable
Viable