Atrioventricular Re-entrant Tachycardia
is also known as AVRT for short.
And it's a type of supraventricular tachycardia
where you have an abnormal loop of electricity,
or a re-entrant circuit,
going around and around between two pathways.
So you have to have two pathways,
one being normal AV conduction system,
so that's one of the pathways.
And the other pathway is an accessory pathway.
And that's just an extra pathway
that exists between the atrium and the ventricle.
And atrioventricular re-entrant tachycardia.
So I'm just going to erase this real quick,
cause we're gonna re-draw that in a second.
So normally, signal goes from the SA node
through the atrium, to the AV node.
And remember, the AV node is sort of like
the gatekeeper, or the bridge that bridges
signal from the atrium to the ventricle.
So in a normal heart, signal has to go
through this AV node.
And it goes through the AV node and down
to the ventricles and causes
ventricular stimulation and contraction.
Sometimes there's an abnormal path,
or an accessory pathway,
which is an extra pathway between
the atrium and the ventricle.
So it could be here,
it could be over here,
I just drew over here for convenience.
But there's this extra pathway.
And signal can travel from the atrium
to the ventricle through this pathway
and excite ventricular tissue that way.
Signal can also go from the ventricles
through the atrium through this accessory pathway.
So it can either go forward,
or in the anterograde direction,
which is from the atrium to the ventricle,
or backwards, which is the retrograde direction.
From the ventricles to the atrium.
And the direction that it goes
depends on a couple of things.
It depends on the timing of the refractory period
of the accessory pathway.
And the refractory period, remember,
that's the window of time
right after a group of cells are excited,
in which they can't be excited again.
It's kind of like a recovery period.
So say you sprinted 100 meters.
You're not gonna be ready to sprint
another 100 meters unless you take a little break.
So the refractory period is sort of like
a mini-recovery period.
And again, whether or not the signal goes
in this forward direction or this backwards direction
depends on the timing of the refractory period
of the accessory pathway, as well as
the direction from which signal is coming
towards this accessory pathway.
So if you have normal conduction through
the AV node, and you have an accessory pathway,
this can set you up to have a re-entrant circuit,
or this abnormal loop electrical activity
going around and around and around,
which could cause a tachyarrhythmia.
So again, you need to have both a working
AV conduction system and this accessory pathway
in order to have AVRT.
I think one of the best ways to better
conceptualize AVRT is by going through
the most classic example of AVRT,
which is Wolff-Parkinson-White syndrome.
So again, Wolff-Parkinson-White syndrome
is a classic example of AVRT.
And sometimes it's called WPW for short.
So again, in Wolff-Parkinson-White syndrome,
you have this extra pathway
or accessory pathway that exists between
the atrium and the ventricle.
And you have signal that goes from the SA node
to the AV node, and then to the ventricles
and that signal can also go from the SA node
through this accessory pathway
and can stimulate the ventricles that way.
So you're getting ventricular stimulation
through the AV node and through
this accessory pathway.
Now something to note is that the AV node
has special tissue that actually
slows down conduction so when signal
hits the AV node, the conduction slows down.
However, this accessory pathway is just kind
of like a hole between the atrium and the ventricle.
It's not gonna slow down any signal.
So the signal going from the atrium to the ventricle
through this pathway is actually going
to stimulate ventricular cells sooner
than it would the AV node,
cause this AV node has this built-in
mechanism that slows down conduction.
So you're going to see some changes on the EKG.
You're going to see a shortened PR interval,
and you're gonna see the slow rise
in the slope of the QRS.
Again, you have this shortened PR interval,
the PR interval is usually less than 0.12 seconds.
And that's because you have this pre-excited
ventricular tissue that's getting stimulated
before the normal conduction system has
a chance to stimulate ventricular tissue.
And because you're getting ventricular
stimulation over a longer period of time,
you're gonna have this slow rise in your QRS.
This slow rise is called a Delta wave.
And again, this is classic for WPW.
Now it's important to note that this here is not AVRT.
You're not gonna get a tachyarrhythmia just from this.
However, in the event that you have
a premature beat coming from the SA node
going to the AV node,
and if this accessory pathway happens
to be in a refractory period,
meaning that the signal isn't gonna travel
this way through the accessory pathway,
then you're gonna have signal going down
through the ventricles.
It's gonna travel back up.
And by the time it reaches the
accessory pathway, it will no longer
be in a refractory period.
So the signal can actually travel
through the accessory pathway and then go back
and stimulate the AV node.
This creates the re-entry circuit.
So you're gonna have the signal
going around and around and around and around.
And this is gonna create the tachyarrhythmia
that you get in AVRT.
Atrioventricular Nodal Re-entrant Tachycardia
is another type of re-entrant tachycardia
like AVRT, but it has its differences.
So people call this AVNRT for short.
Remember, this is very different than AVRT.
It's called AVNRT, N is for Nodal,
because the abnormal loop of electricity,
or that abnormal re-entrant circuit,
directly involves the AV node.
And the tissue right around it.
There is no accessory pathway in AVNRT.
So again, this is the AV node,
and here I drew a bigger AV node.
I kind of blew it up.
So this is the AV node,
and the His Bundle, and the conduction system
going down into the ventricles.
So in AVNRT, there are two pathways
that run through the AV node.
There's a slow pathway,
where an impulse travels more slowly down the path,
and there's a fast pathway
where the impulse can zip through.
Now I'm gonna erase this real quick,
cause we're gonna re-draw these in a second.
Okay, something else to note.
Just because of this inherent make up,
the slow pathway has a shorter refractory period.
Now remember the refractory period
is that window of time when cells can't be excited
again after they've already been excited.
Whereas the fast pathway has
a longer refractory period.
I'm gonna abbreviate refractory period RP.
Refractory period.
So again: slow pathway, short refractory period.
Fast pathway, long refractory period.
So a signal comes down, and it's gonna split.
And it's gonna rush down the fast pathway,
reach this common final pathway,
and then spread to the ventricles.
Meanwhile, it's gonna slowly go down
the slow pathway.
After this impulse has been transmitted
through this fast pathway,
it's gonna go through the refractory period.
So these lines through it mean refractory period.
By the time the slow pathway signal
makes it to the final common pathway,
it's gonna hit the refractory period
of the fast pathway,
and it's gonna terminate.
Because no signal can be activated this way
since it's in refractory period.
This slow pathway is gonna enter its own
refractory period, a shorter refractory period.
So it's actually gonna recover.
And then the fast will recover.
And both the slow and fast pathway
are ready for business again.
They're ready for another impulse.
Now let's say that there's an early beat,
or a premature beat that comes in.
Sometimes people call these extra beats.
So there's an early beat that comes in.
And let's say it comes in at a time
when the fast track is still recovering
from a refractory period,
but the slow track has already recovered
from its refractory period and is open.
So this beat's gonna send impulse down
the slow track.
As the slow track slowly makes its way down
the slow track,
the fast track is gonna recover
from its refractory period.
So by the time the impulse reaches this
final common pathway,
it's gonna send signal down.
And because the fast track has recovered
from its refractory period,
this impulse can activate the fast track
and send signal back up.
If the slow track has already been
through its refractory period and
recovered from that refractory period,
it can activate the slow pathway.
And send signal back down.
And what happens is,
the impulse will continue to circle
around and around.
You're creating this re-entrant loop.
And as it circles around and around and around,
it's gonna keep sending signal down this way.
So this loop is sending signal through
the AV node at a much faster rate
than a normal pace maker's would,
so you might see a heart rate between
100 to even 250 beats per minute.
And again, it's because you have this
abnormal re-entrant loop,
sending signal around and around and around
which is gonna spit off signal
down to the ventricles at a much faster rate
than a normal pacer's would.
EKG is gonna look like a supraventricular tachycardia
where you have a narrow QRS complex,
meaning it's less than 0.12 seconds
or three small boxes.
And you're gonna have a heart rate of
greater than or equal to 100 beats per minute.
Because that's what a tachycardia is.
It's greater than 100 beats per minute.
So on this EKG here, you can appreciate
a narrow QRS complex,
and again the QRS complex is narrow
because there's normal activation
of the His Purkinje system,
and you notice that the heart rate
is greater than 100 beats per minute.
So the heart rate here is somewhere between
150 and 300 beats per minute.
By looking from here to here,
you can tell that the heart rate
is above 100 beats per minute.
So this is definitely a tachycardia.