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      Resetting and Entrainment of Reentrant Arrhythmias: Part I: Concepts, Recognition, and Protocol for Evaluation: Surface ECG versus Intracardiac Recordings

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          Abstract

          In this paper, we review the information accumulated over the years regarding the phenomena of resetting and entrainment of reentrant arrhythmias. Over three decades of research and clinical applications, these phenomena have demonstrated that they stay as a main tool for an intellectual understanding of reentry and to base strategies for localization of critical areas for ablative therapies. This review will be divided into two parts. This first part deals with the bases for the concept development, the means for the detection of these phenomena, and their mechanistic implications. Resetting is described as a particular response of a given rhythm to an external perturbation, indicating interaction between them. Entrainment indicates continuous reset of the rhythm when the perturbation is repetitive. The mechanisms that explain these responses in reentrant rhythms are presented. Fusion, both at the surface electrocardiogram and at the level of intracardiac recordings, is discussed in detail, with its value and limitations as a key concept to recognize entrainment and reentry. Computer simulations are used as an aid to a better understanding. Differences between resetting and entrainment are considered, and a pacing protocol to study these phenomena described.

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          Further observations on transient entrainment: importance of pacing site and properties of the components of the reentry circuit.

          A Waldo, Adrian Epstein, R W Henthorn … (1985)
          Transient entrainment of circus-movement tachycardia utilizing an atrioventricular (AV) bypass pathway was studied in 13 patients (nine with the orthodromic form, two with the antidromic form, and two with both the orthodromic and antidromic forms). All patients had a left-sided AV bypass pathway. Pacing at selected rates faster than the spontaneous rate was performed during the tachycardia at a site proximal or distal to the AV node, an area of slow conduction within the reentry loop. Rapid pacing from a site proximal to the AV node (from the right atrium during the orthodromic form of the arrhythmia or the right ventricle during the antidromic form of the arrhythmia) always demonstrated at least one of the three entrainment criteria: constant fusion beats except for the last captured beat, which was entrained but not fused (first criterion); progressive fusion (second criterion); localized conduction block to a site(s) for 1 paced beat associated with interruption of the tachycardia followed by activation of that site(s) by the next paced beat from a different direction and with a shorter conduction time (third criterion). In contrast, rapid pacing from a site distal to the AV node (from the right ventricle during the orthodromic form of the arrhythmia, or the right atrium during the antidromic form of the arrhythmia) transiently entrained the tachycardia, but never demonstrated any entrainment criteria because the antidromic wave front from the pacing impulse always blocked in the AV node (concealed entrainment). We conclude that the location of the pacing site relative to the components of a reentry loop is critical to the demonstration of the criteria of transient entrainment; i.e., if it is proximal to an area of slow conduction and/or unidirectional block within a reentry loop, transient entrainment should be demonstrable, but if it is distal, it will not be demonstrable.
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            Ventricular fusion during resetting and entrainment of orthodromic supraventricular tachycardia involving septal accessory pathways. Implications for the differential diagnosis with atrioventricular nodal reentry.

            J Almendral, J P Villacastín, J. Martínez … (1993)
            Ventricular fusion during transient entrainment of orthodromic atrioventricular reciprocating tachycardias (OAVRT) was originally found to be absent and recently observed only with left ventricular stimulation. However, previous studies were restricted to cases with a left free wall accessory pathway. The hypothesis of the present study was that fusion is likely during resetting and entrainment of OAVRT with right ventricular stimulation if the accessory pathway is septally located, since its insertion is relatively close to the stimulation site. This phenomenon can help in the differential diagnosis with atrioventricular nodal reentry (AVNR). We performed programmed right ventricular stimulation during regular inducible supraventricular tachycardia with concentric atrial activation in 44 patients--20 with OAVRT and 24 with AVNR. Fusion in the ECG morphology of extrastimuli producing resetting was observed in 19 of 19 OAVRT but in 0 of 11 AVNR reset (P < .001). Transient entrainment was demonstrated in all 31 cases undergoing rapid ventricular pacing (14 OAVRT and 17 AVNR). Entrainment with fusion occurred in 13 of 14 OAVRT and in 0 of 17 AVNR (P < .001). Fusion was critically dependent on the coupling intervals or pacing rates, sometimes having a narrow window for its observation. The relative proximity (conduction time) among pacing site, site of entrance to a reentrant circuit, and site of exit from the circuit to the paced chamber are critical for the occurrence of fusion during resetting and/or entrainment. The presence or absence of fusion during these phenomena can help in the differential diagnosis of certain supraventricular tachycardias.
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              From bedside to bench: entrainment and other stories.

              A Waldo (2004)
              The concepts of transient entrainment of reentrant rhythms started with studies of overdrive pacing of atrial flutter (AFL) in patients in the immediate period after open heart surgery. Initial studies demonstrated the need to achieve a critical pacing rate and a critical duration of pacing at the critical pacing rate to interrupt AFL. Further pacing studies of AFL, ventricular tachycardia, atrioventricular (AV) reentrant tachycardia, AV nodal reentrant tachycardia, and atrial tachycardia refined the understanding of what occurs during overdrive pacing of reentrant tachycardias, and permitted a mechanistic understanding of transient entrainment as continuous resetting of a reentrant tachycardia to a pacing rate that is faster than the rate of the tachycardia, but which fails to interrupt it. The demonstration of transient entrainment of a tachycardia provides a reliable clinical tool to establish the presence of a reentrant rhythm. Moreover, the principles of entrainment have also been applied clinically to assist in effective application of antitachycardia pacing and catheter ablation techniques.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Pacing Clin Electrophysiol
                Journal ID (iso-abbrev): Pacing Clin Electrophysiol
                Journal ID (publisher-id): pace
                Title: Pacing and Clinical Electrophysiology
                Publisher: Blackwell Publishing Ltd
                ISSN (Print): 0147-8389
                ISSN (Electronic): 1540-8159
                Publication date (Print): April 2013
                Publication date (Electronic): 10 January 2013
                Volume: 36
                Issue: 4
                Pages: 508-532
                Affiliations
                [* ]Cardiac Arrhythmia UnitGrupo Hospital de Madrid, Universidad CEU-San Pablo Madrid, Spain
                [† ]Department of Signal Theory and Communications, University Rey Juan Carlos Fuenlabrada, Spain
                Author notes
                Address for reprints: Jesús Almendral, M.D., Ph.D., Hospital Madrid Monteprincipe, Unidad de Electrofisiología Cardiaca (Sala de Electrofisiología), Avda Monteprincipe, 25, 28660 Boadilla del Monte, Madrid, Spain. Fax: 34-912110113; e-mail: almendral@ 123456secardiologia.es
                Article
                DOI: 10.1111/pace.12064
                PMC ID: 3666092
                PubMed ID: 23305213
                SO-VID: 1b4478ce-36a5-41dc-96e7-af594c8c62a8
                Copyright © © 2013 Wiley Periodicals, Inc.
                License:

                Re-use of this article is permitted in accordance with the Creative Commons Deed, Attribution 2.5, which does not permit commercial exploitation.

                History
                Date received : 31 August 2012
                Date revision received : 14 October 2012
                Date accepted : 24 November 2012
                Categories
                Subject: Review

                Keywords: resetting,entrainment,reentry,tachycardia,fusion,pacing
                Data availability:
                Keywords: resetting, entrainment, reentry, tachycardia, fusion, pacing

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