Overview

In this course, we explain the re-entrant mechanism generating ventricular tachycardia in the setting of structural heart disease. We explain the mechanism underlying incomplete AV dissociation in a ventricular tachycardia. We will teach you how to recognise this diagnostically important phenomenon on the ECG. You will learn how to divide cases of broad complex tachycardia into right or left bundle branch block morphologies. We teach you aspects of ECG analysis which will help you to make the crucial distinction between VT and SVT with aberrancy. You will learn how to interpret the presence or absence of a response to intravenous adenosine in a broad complex tachycardia. We discuss variants of ventricular tachycardia occurring in the absence of structural heart disease and their identification on the ECG. We will also teach you how to recognise artefact on the ECG mimicking VT (‘pseudo-ventricular tachycardia’). We detail the terminology used in the description of ventricular tachycardia. The ‘essential reading’ section of the bibliography contains links to papers which have been selected to reinforce and enhance the lessons learned in the videos. These papers should be read before attempting the quiz. In the quiz, we present informative clinical cases which will confirm that you have acquired the skills listed in the learning objectives of this course and which will, reinforce those skills.

Faculty

Planner and Author: Dr John Seery MB PhD

• Consultant Physician at St. Vincent's University Hospital, Dublin, Ireland
• Lecturer at the School of Medicine and Medical Science, University College Dublin, Ireland
• Studied medicine at the University of Cambridge, United Kingdom
• A Natural Sciences graduate of Trinity College Dublin, Ireland
• PhD in Cell Biology from University College London, United Kingdom

Planner: Dr Karen Strahan PhD (University of Cambridge), Head of Editorial
Planner: Tommy O'Sullivan, CME Manager
 

Estimated Time to Complete

5.0 hours

Target Audience

• Physicians
• Nurses
• Nurse Practitioners
• Physician Assistants
• Paramedics

Learning Objectives

Upon successful completion of this activity, you will be able to:

• Define the term ventricular tachycardia
• Explain the re-entrant mechanism underlying ventricular tachycardia in structural heart disease
• Determine the bundle branch block morphology of a broad complex tachycardia
• Recognize ECG evidence of AV dissociation during a broad complex tachycardia
• Appropriately utilize and interpret the response to intravenous adenosine in a broad complex tachycardia
• Avoid administration of intravenous adenosine in cases of atrial fibrillation with aberrancy
• Use appropriate language in the description of VT
• Identify pseudo-ventricular tachycardia on the ECG, thereby avoiding inappropriate medical intervention

Course Content

• Introduction
• The Frontal Schematic
• The Transverse Schematic
• Defining Ventricular Tachycardia
• Monomorphic VT 'Figure of 8 Re-Entry'
• Before We Go On
• Broad Complex Tachycardia (BCT) Bundle Branch Block Morphology
• Monomorphic VT Mean qrs Axis and Precordial Concordance
• Atrial Depolarization in Ventricular Tachycardia
• Mechanism of AV Dissociation in Ventricular tachycardia
• AV Dissociation Recognition Capture Beats
• AV Dissociation Recognition Dressler Beats
• AV Dissociation Recognition P Wave Fusion
• AV Dissociation Recognition Caveats
• Adenosine and Ventricular Tachycardia Diagnosis
• Monomorphic Ventricular Tachycardia Nomenclature
• Case Study Rhythm is King
• Quiz
• Post Quiz Explanatory Video Q1 - Q10
• Post Quiz Explanatory Video Q11 - Q15
• Post Quiz Explanatory Video Q16 - Q20
• Essential Reading

Release date

06-DEC-2023

Expiration date

06-DEC-2026

Instructions for Participation

Participants must complete the online activity during the valid period as noted above.
Follow these steps:

1. View videos in sequence
2. Read the papers on the Essential Reading List
3. Complete the quiz
4. View and complete post quiz video to support learning outcomes and objectives
5. Complete the activity evaluation form to provide feedback for continuing education purposes and for the development of future activities
6. Download the Certificate of Completion

Relevant Financial Disclosures

Acadoodle adheres to the ACCME's Standards for Integrity and Independence in Accredited Continuing Education. Any individuals in a position to control the content of a CE activity, including faculty, planners, reviewers or others are required to disclose all relevant financial relationships with ineligible entities (commercial interests). All relevant conflicts of interest have been mitigated prior to the commencement of the activity.

Planners and faculty for this activity have no relevant financial relationships with commercial interests to disclose.

Bibliography

Grant RP. Spatial Vector Electrocardiography: A Method for Calculating the Spatial Electrical Vectors of the Heart from Conventional Leads. Circulation. 1950;11:676-95.
https://www.ahajournals.org/doi/pdf/10.1161/01.CIR.2.5.676

Martin R et al. Ventricular tachycardia isthmus characteristics: Insights from high density mapping. Arrhythmia & Electrophysiol Review. 2019;8(1).
https://www.aerjournal.com/articles/ventricular-tachycardia-isthmus

Martin R et al. Characteristics of scar-related tachycardia circuits using ultra-high-density mapping. Circulation: Arrhythmia and Electrophysiology. 11(10).
https://www.ahajournals.org/doi/10.1161/CIRCEP.118.006569

Goldreyer BN and Biggar JT. Ventriculo-atrial Conduction in Man. Circulation. 1970:71:935-46.
https://www.ahajournals.org/doi/pdf/10.1161/01.CIR.41.6.935

Papanastasiou CA et al. A rare case of pseudo-atrial flutter waves in a patient with essential tremor. Cureus 2019;11(1):e3934. DOI 10.7759/cureus.3934
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6430307/

Wang KW and Benditt DG. AV Dissociation, an Inevitable Response. Ann Noninvasive Electrocardiol. 2011;16(3):227-31.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6932318/pdf/ANEC-16-227.pdf

Kistin AD. Retrograde Conduction to the Atria in Ventricular Tachycardia. Circulation. 1961;24:236–249.
https://www.ahajournals.org/doi/10.1161/01.CIR.24.2.236

de Riva M et al. Twelve-Lead ECG of Ventricular tachycardia in Structural Heart Disease. Circulation. 2015;8(4):951-62.
https://www.ahajournals.org/doi/full/10.1161/CIRCEP.115.002847

Igarashi M et al. Radiofrequency Catheter Ablation of Ventricular Tachycardia in Patients With Hypertrophic Cardiomyopathy and Apical Aneurysm. JACC Clin Electrophysiol. 2018;4(3):339-50.
https://electrophysiology.onlinejacc.org/content/jcep/4/3/339.full.pdf

Enriquez A et al. How to use the 12-lead ECG to predict the site of origin of idiopathic ventricular arrhythmias. Heart Rhythm. 2019;16:1538-44.
https://www.heartrhythmjournal.com/article/S1547-5271(19)30302-9/fulltext

Mizuno H. Mapping of ventricular tachycardia in patients with structural heart disease. J Arrhythm. 2014;30(4):283-91.
https://www.sciencedirect.com/science/article/pii/S1880427614001008

Garmel GM. Wide Complex Tachycardias: Understanding this Complex Condition Part 1 – Epidemiology and Electrophysiology. West J Emerg Med. 2008;9:28-39.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2672229/pdf/wjem-9-0028.pdf

Hakan O et al. Adenosine-Responsive Wide QRS Complex Tachycardia: What is the Mechanism? J Cardiovasc Electrophysiol. 1990:10;1688-9.
https://deepblue.lib.umich.edu/bitstream/handle/2027.42/75283/j.1540-8167.1999.tb00233.x.pdf?sequence=1

Marriot HJL et al. Ventricular Fusion Beats. Circulation. 1962;26: 880-4.
https://www.ahajournals.org/doi/pdf/10.1161/01.CIR.26.5.880

Vereckei A. Current Algorithms for the Diagnosis of wide QRS Complex Tachycardias. Curr Cardiol Reviews. 2014:10:262-76.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4040878/pdf/CCR-10-262.pdf

Alzand BSN and Crijns HJGM. Diagnostic criteria of broad QRS complex tachycardia: decades of evolution. EP Europace. 2011;13(4):465-72.
https://academic.oup.com/europace/article/13/4/465/427753

Knight BP et al. Clinical consequences of electrocardiographic artefact mimicking ventricular tachycardia. N Engl J Med. 1999;341:1270-4.
https://www.nejm.org/doi/full/10.1056/nejm199910213411704

ACCME Accreditation Statement

Acadoodle, Ltd is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Credit Designation Statement

AMA Physician’s Recognition Award

Acadoodle, Ltd designates this enduring material activity for a maximum of 5.0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.