Contemporary Management of SVT

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Contemporary Management of SVT

• DHCM Cardiology
• Core Curriculum

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Location of P Wave During SVT Offers Clue to
Mechanism

• No visible P wave or ultrashort RP interval
  typical for AVNRT
• Short RP tachycardia typical for ORT
• Long RP tachycardia typical for AT

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Pre-excited AFib Can Lead to VF
Courtesy of Dr. Brian Olshansky.
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A 30-year-old male presents to the emergency room
with a wide complex, irregularly irregular
tachycardia at 250 beats per minute. He has no
prior cardiac history. He is relatively
comfortable, with a blood pressure of 100
systolic. The most appropriate therapy would be

• A. Adenosine.
• B. Intravenous diltiazem.
• C. Intravenous digoxin.
• D. Intravenous lidocaine.
• E. Intravenous ibutilide.

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Acute Management of Pre-excited Afib

• Avoid IV AV nodal active drugs (possible
  exception beta blocker)
• Ibutilide for stable patient
• Electrical cardioversion

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Acute Management of Generic SVT

• First choices Vagal maneuvers, IV adenosine
• Second choices IV verapamil or diltiazem
• Subsequent choices beta blockade, IV ibutilide

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Chronic Medical Management of Generic SVT

• AV nodal active drugs alone or in combination
• Add antiarrhythmic drug to above (flecainide or
  propafenone in absence of structural heart
  disease)
• Daily Rx vs. pill in the pocket approach

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Catheter Ablation for Generic SVT

• First line therapy for lifestyle-impairing
  symptoms, prior to drug Rx
• Overall cure rate 90 with single session
• Complication rate lt2-3

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The CryoTherapy ZoneUnderstanding the Dynamic
Thermal Gradient
CryoMapping
CryoAblation
The zone is thermally dynamic over time cells
remaining above zero sustain a transient
electrical effect, cells reaching and remaining
at sub-zero temperatures are ablated.
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WPW Epidemiology

• Symptoms develop in about 1/3 of patients lt40
  years, fewer patients gt40 years
• Sudden death occurs in about 0.1-0.4 of
  patients with WPW
• Sudden death as the first symptom is very rare

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WPW Management Considerations

• Mild symptoms consistent with tachycardia warrant
  at least an EPS to assess risk for sudden death
• Catheter ablation first-line therapy for
  lifestyle-impairing symptoms (and selected
  asymptomatic patients with abnormal EPS e.g.
  athletes, pilots, family hx sudden death, ?
  others)
• Avoid digoxin

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Atrial Fibrillation Pathophysiology
Vagal fibers
SupraventricularTachycardia
?RF Target 4
RF Target 1
RF Target 3
AtrialSubstrate
Flutter, AT,ORT, AVNRT,
PSVT
PAF
electricalremodeling
Paroxysmal AF
Persistent AF
structuralalterations
RF Target 2
Atrial Prematures
PV origin (67-95)Other sites
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Acute Management of Afib/flutter

• Rate control (beta blockers and calcium blockers
  preferred)
• Anticoagulation
• Consider electrical or pharmacologic
  cardioversion (TEE may be necessary)

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Chronic Management of Afib/flutter

• Assess embolic risk and use warfarin or ASA
  accordingly
• Rate control
• Consider restoration of sinus rhythm (symptoms,
  poor rate control, first episode, ? selected
  patients with minimal symptoms)
• Consider ablation

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Percent of total strokes attributable to AF
Age group (years)

• 35 of patients with AF who are not treated with
  anticoagulants will have a stroke in their
  lifetime

Stroke, 1991, 22(8) 9388
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Warfarin Use in AF Patients by Age
Annals of Internal Medicine, 1999 131(12)
927-934
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LA Appendage Occlusion SystemAtritech WATCHMAN?
External View of LAA
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WATCHMAN LAA System Internal view of Complete
Healing of LA
Canine 45 days
Human _at_ Autopsy 9 mos
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Which of the following statements is correct?A.
Atrial flutter is most commonly due to
microreentry in the right atrial free wall.B.
Catheter ablation for atrial flutter always
requires a transseptal puncture for left atrial
ablation.C. Atrial flutter is most commonly a
macroreentrant circuit in the right atrium, and
linear cavotricuspid isthmus ablation can cure
this tachycardia in about 90 of patients.D.
Patients with multiple episodes of atrial
fibrillation as well as atrial flutter are likely
to be cured of atrial fibrillation with an
ablation targeting the atrial flutter substrate
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Catheter Ablation of Right Atrial Flutter

• First line therapy--much more effective than
  medical therapy
• 85-90 cure rate low risk of complications
• Best candidates minimal or no atrial
  fibrillation (on or off antiarrhythmic medication)

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A 52-year-old female is having lone, paroxysmal
atrial fibrillation with a rapid
ventricularresponse about once a week, usually
terminating spontaneously in several hours,
althoughshe has required two emergency room
visits in the last six months. She has failed
flecainide 150 mg twice daily in combination with
metoprolol and diltiazem, as well as sotalol 160
mg twice daily in combination with diltiazem. The
most attractive strategy for this patient would
be A. Propafenone. B. Dofetilide. C.
Amiodarone. D. AV junction ablation with
permanent
pacer. E. Left atrial
ablation for atrial fibrillation.
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Left Atrial Ablation for Afib

• Indicated for lifestyle-impairing symptoms,
  despite antiarrhythmic drug therapy (? first line
  therapy)
• Success rates modest (60-80) even with repeat
  procedures
• Asymptomatic recurrences not uncommon (?warfarin
  needed indefinitely)