Unknown QRS Morphology Change at Peak Exercise: To Stop or to Continue?

Electrocardiogram changes during stress tests are well standardized and understood. We present and explain a reversible QRS morphology change at peak exercise previously unreported. (Level of Difficulty: Intermediate.).

Interpretation of Typical and Atypical Atrial Flutters by Precision Electrocardiology Based on Intracardiac Recording.

Atrial flutter is a term encompassing multiple clinical entities. Clinical manifestations of these arrhythmias range from typical isthmus-dependent flutter to post-ablation microreentries. Twelve-lead electrocardiogram (ECG) is a diagnostic tool in typical flutter, but it is often unable to clearly localize atrial flutters maintained by more complex reentrant circuits. Electrophysiology study and mapping are able to characterize in fine details all the components of the circuit and determine their electrophysiological properties. Combining these 2 techniques can greatly help in understanding the vectors determining the ECG morphology of the flutter waveforms, increasing the diagnostic usefulness of this tool.

Relationships Between Atrial Flutter and Fibrillation: The Border Zone.

Atrial flutter and fibrillation have been inextricably linked in the study of electrophysiology. With astute clinical observation, advanced diagnostic equipment in the Electrophysiology Laboratory, and thoughtful study of animal models, the mechanism and inter-relationship between the 2 conditions have been elucidated and will be reviewed in this article. Though diagnosis and management of these conditions have many similarities, the mechanisms by which they develop and persist are quite unique.

Typical Atrial Flutter Mapping and Ablation.

Isthmus-dependent flutter represents a defeated arrhythmia. Possibly one of the most outstanding successes in terms of understanding the mechanism behind it has led to an effective, relatively simple, and safe targeted therapy. Technology, fulfilling a number of the clinical electrophysiologist's dreams, has linked diagnosis and therapy in computerized systems showing real-time imagines of the right atrium, the arrhythmia circuit, and the ablation target. The entire history of clinical electrophysiology is contained in its path and atrial flutter needs to be regarded with immense respect for a large amount of knowledge that its study always engenders."

The History of Atrial Flutter Electrophysiology, from Entrainment to Ablation: A 100-Year Experience in the Precision Electrocardiology.

Atrial flutter (AFL) is a regular supraventricular reentrant tachycardia generating a continuous fluttering of the baseline electrocardiography (ECG) at a rate of 250 to 300 beats per minute. AFL is classified based on the involvement of the cavo-tricuspid isthmus in the circuit. The "isthmic" (or type 1) AFL develops entirely in the right atrium; this circuit is commonly activated in a counter-clockwise direction, generating the common sawtooth ECG morphology in the inferior leads (slow descendent-fast ascendent). AFL can be nonisthmus dependent (type 2), often presenting with faster atrial rate and most commonly a left atrial location.

Electrocardiographic Approach to Atrial Flutter: Classifications and Differential Diagnosis.

Atrial flutter (AFL) is a macro-reentrant arrhythmia characterized, in a 12 lead ECG, by the continuous oscillation of the isoelectric line in at least one lead. In the typical form of AFL, the oscillation is most obvious in the inferior leads, due to a macro-reentrant circuit localized in the right atrium, with the cavo-tricuspid isthmus as a critical zone.: This circuit can be activated in a counterclockwise or clockwise direction generating in II, III, and aVF leads, respectively, a slow descending/fast ascending F wave pattern (common form of typical AFL) or a balanced ascending/descending waveform (uncommon form of typical AFL). Atypical AFLs (scar-related) do not include the CTI in the circuit and show an extremely variable circuit location and ECG morphology.

Pathophysiology of Atypical Atrial Flutters.

Atypical atrial flutters are complex supraventricular arrhythmias that share different pathophysiological aspects in common. In most cases, the arrhythmogenic substrate is essentially embodied by slow-conducting areas eliciting re-entrant circuits. Although atrial scarring seems to promote slow conduction, these arrhythmias may occur even in the absence of structural heart disease. To set out the ablation strategy in this setting, three-dimensional mapping systems have proved invaluable over the last decades, helping the cardiac electrophysiologist understand the electrophysiological complexity of these circuits and easily identify critical areas amenable to effective catheter ablation.

Mapping and Ablation of Atypical Atrial Flutters.

Atypical atrial flutters are complex, hard-to-manage atrial arrhythmias. Catheter ablation has progressively emerged as a successful treatment option with a remarkable role played by irrigated-tip catheters and 3D electroanatomic mapping systems. However, despite the improvement of these technologies, the ablation results may be still suboptimal due to the progressive atrial substrate modification occurring in diseased hearts. Hence, a patient-tailored approach is required to improve the long-term success rate in this scenario, aiming at achieving specific procedure end points and detecting any potential arrhythmogenic substrate in each patient.

Atypical Cases of Typical Atrial Flutter? A Case Study.

Ablation of typical atrial flutter has a high safety and efficacy profile, but hidden pitfalls may be encountered. In some cases, a longer cycle length with isoelectric lines is associated with a different or more complex arrhythmogenic substrate, which may be missed if conduction block of the cavotricuspid isthmus is performed in the absence of the clinical arrhythmia. Prior surgery may have consistently modified the atrial substrate and complex or multiple arrhythmias associated with an isthmus-dependent circuit can be encountered. In these cases, electroanatomic mapping is useful to guide the procedure and plan an appropriate ablation strategy.

Change of Paradigm in the Management of Patients with Accessory Pathways over the Last Forty Years: Wolff-Parkinson-White Syndrome as an Electrophysiological Marvel at Risk of Extinction.

Over the last decades, the approach to the Wolff-Parkinson-White syndrome, as well as its treatment, has substantially changed, leading to improvement in the prognosis and quality of life of these patients. From the first diagnostic electrophysiologic studies to the most recent evaluations, important data on pathophysiologic and clinical aspects have been gathered, and this learning journey is still not concluded. This body of knowledge is a fundamental part of any cardiologists' armamentarium despite the fact that this syndrome is rarely observed in adult patients.

Arrhythmias with Bystander Accessory Pathways.

An accessory pathway (AP) could manifest its presence exclusively during an orthodromic supraventricular tachycardia or with preexcitation during sinus rhythm (SR). The manifestations of the presence of an AP depend on its ability to conduct antegradely from atrium (A) to ventricle (V), retrogradely (V to A), or both. AP retrograde conduction is necessary to establish an atrioventricular reentrant tachycardia circuit. If an AP can only conduct antegradely, it will function as a bystander AV connection during independent arrhythmias. The correct diagnosis of this condition is very important, as it will determine the immediate and long-term management.

Clinical Approach to Symptomatic and Asymptomatic Patients with Ventricular Pre-excitation.

Despite extensive knowledge of the physiopathology of ventricular pre-excitation, management of asymptomatic patients with this condition remains controversial.

Ventricular Preexcitation: An Anomalous Wave Interfering with the Ordered Ventricular Activation.

Ventricular preexcitation is a depolarization of the ventricles that occurs before the conventional sequence, and the electrocardiogram is the specific test for diagnosis. A Kent bundle is the paradigm of ventricular preexcitation, and it is associated with short PR, wide QRS and delta wave. This finding is not always very evident, as it can have different degrees of pre-eccitazione; therefore great diagnostic care must be taken in this field. If not properly identified, the pattern of ventricular preexcitation may lead to an incorrect diagnosis. The methodology of precision electrocardiology is able to confront all these aspects.

Accessory Pathway-Mediated Tachycardias: Precision Electrocardiology Through Standard and Advanced Electrocardiogram Recording Techniques.

An accessory pathway (AP) can be apparent during sinus rhythm if it depolarizes part of the ventricles ahead of the normal wave front from the conduction system. An AP can generate an anatomic circuit able to sustain a macroreentrant atrioventricular reentrant tachycardia. This arrhythmia can engage the normal conducting system in an antegrade direction or retrogradely, generating, respectively, a narrow or a wide complex tachycardia. The combined use of a standard electrocardiogram and an esophageal recording-pacing can be particularly useful in the first approach to patients with Wolff-Parkinson-White syndrome, further stratifying patients requiring electrophysiology study and transcatheter ablation.

Arrhythmias Involving Variants of Accessory Pathways.

In some cases, atrioventricular reentrant arrhythmias are sustained by accessory pathways with peculiar electrophysiologic properties related to their specific anatomy. Most of these fibers, which may be responsible for variants of ventricular preexcitation, show decremental conduction properties due to a nodelike aspect or a peculiar tortuous anatomic route across the atrioventricular groove. Moreover, some fibers do not actively sustain any reentrant circuit and can be only involved as bystander in other arrhythmias. Although rare, these accessory pathway variants should be properly diagnosed using noninvasive and invasive methods to guide catheter ablation procedures when needed.

Ablation of Accessory Pathways with Challenging Anatomy.

Although catheter ablation of accessory pathways is deemed highly safe and effective, peculiar location of these pathways might lead to complex and potentially hazardous procedures requiring ablation in anatomic regions such as para-Hisian area, coronary sinus, and epicardial surface. The electrophysiologist should know these possible scenarios to plan the best strategy for safe and effective ablation of these uncommon accessory pathways.

Precision Electrocardiology: A Rational Approach for Simple and Complex Arrhythmias.

Electrocardiography (ECG) in all its forms, from 12-lead ECG to long-term monitoring, is considered, an old and increasingly irrelevant test in this high technology era. This article reviews the clinical utility of this tool and argues that the obsolescence is due to an increasing inability to read electrocardiographic tracings. The usual interpretative pitfalls are discussed and a logical approach is proposed with illustrative examples. Finally, the concept of precision ECG is presented and its meaning reviewed.

Electrocardiographic Approach to Complex Arrhythmias: P, QRS, and Their Relationships.

When faced with an electrocardiographic recoding of a complex arrhythmia, we often use inflexible algorithms or try to recall patterns already seen, which is often insufficient to explain the mechanisms of difficult bradycardias and tachycardias. We propose an approach to these situations where, starting from basic observations, the behavior of the different components of the arrhythmia is reconstructed using logical deductions. The extensive use of laddergrams faithfully illustrates how analysis of timing of each visible event, P and QRS, clarifies their relationship and dictates the behavior of electrocardiographic silent cardiac structures (sinus node and atrioventricular node).

Challenges in Bradicardias Interpretation.

Sinus node dysfunction or atrioventricular blocks are the causes of bradycardias. Diagnosis and management begin with evaluation of patient's hemodynamic status and diagnosis of bradycardia's cause. This is followed by an in depth evaluation of pathophysiology of the arrhythmia, its severity, and likelihood of progression. Implementing emergent measures depends on the presence of subsidiary pace makers maintaining cardiac output. Many of these decisions are greatly helped by 12 lead electrocardiogram, because its tracings are often diagnostic of the cause of the bradycardia and help to assess its persistence and progression and to evaluate the presence and reliability of subsidiary pacemakers.

Surface Electrocardiogram Recording: Baseline 12-lead and Ambulatory Electrocardiogram Monitoring.

The 12-lead standard electrocardiogram (ECG) is a 10 second recording of human myocytes electrical activity. Filters and oversampling are necessary in order to acquire a smooth signal without distortion. ECG recordings may display ongoing arrhythmias, and some leads may be helpful in formulating the diagnosis. Advanced modalities of baseline ECG recording can be used to extract additional information with significant prognostic value. Ambulatory ECG (AECG) recording is a long-term and low-cost external recording obtained with 1 to 12 leads lasting from 24 to 30 days. For patient comfort, longer AECG recordings use fewer leads.