بسم الله الرحمن الرحيم ”وقل رب زدنى علما “. Dr: IMRANA ZULFIKAR ASSISSTANT PROFESSOR Surgical dept:
وقل ربى زدنى علما
description
Transcript of وقل ربى زدنى علما
![Page 1: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/1.jpg)
ربى وقل
علما زدنىربى وقل
علما زدنى
![Page 2: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/2.jpg)
CardioMonday Oct.2005
Approach to narrow QRS tachycardias
EL-SAYED M.FARAG (Msc.Cardiology)
![Page 3: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/3.jpg)
Definiton
Narrow QRS complex tachycardias(NCT) are defined as tachyarrhythmias with a rate faster than 100 beats/minute and a QRS duration of 120 msec (0.12 sec) or less, as demonstrated on the electrocardiogram (ECG) or cardiac
monitor .
The normal QRS duration reflects normally synchronous activation of both ventricles through the His bundle, bundle branches, and terminal Purkinje conduction system.
![Page 4: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/4.jpg)
SA node
AV node
Bundleof His
Bundle Branches
Purkinje Fibres
Internodal Pathways
Beat Originates from SA ,atrial tissue or AV Node
QRS Complex: normal, narrow
![Page 5: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/5.jpg)
Sinus tachycardia (ST) Inappropriate sinus tachycardia (IST) Sinoatrial nodal reentrant tachycardia (SNRT) Atrial tachycardia (AT) Multifocal atrial tachycardia (MAT) Atrial fibrillation (AF) Atrial flutter (AFl) Junctional ectopic tachycardia (JET) Nonparoxysmal junctional tachycardia (NPJT) Atrioventricular nodal reentrant tachycardia (AVNRT) Atrioventricular reentrant tachycardia (AVRT)
The narrow QRS complex tachycardias include:
![Page 6: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/6.jpg)
![Page 7: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/7.jpg)
Altered automaticity
Triggered activity
Reentry
Mechanisms
![Page 8: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/8.jpg)
Hypothermia decrease, hyperthermia increase phase 4 slope
Hypoxia & hypercapnia both increase phase 4 slope
Cardiac dilation increases phase 4 slope
Local areas of ischemia or necrosis increases automaticity of neighboring cells
Hypokalemia increases phase 4 slope, increases ectopics, prolongs repolarization
Hyperkalemia decreases phase 4 slope; slow conduction, blocks
1. Altered Automaticity
![Page 9: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/9.jpg)
2. Triggered Activity
Afterdepolarization reaches threshold
Early: interrupt repolarization
Delayed: after completion of AP.
![Page 10: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/10.jpg)
3. Reentry
Requires: available circuit, unidirectional block, and different conduction speed in limbs of circuit
Exp: WPW reciprocating tachycardia, AV-nodal reentry, …..
![Page 11: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/11.jpg)
![Page 12: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/12.jpg)
Fast Conduction PathSlow Recovery
Slow Conduction PathFast Recovery
The “Re-Entry” Mechanism of Ectopic Beats & Rhythms.
Electrical Impulse
Cardiac Conduction
Tissue
Tissues with these type of circuits may exist:• in microscopic size in the SA node, AV node, or any type of heart tissue• in a “macroscopic” structure such as an accessory pathway in WPW
![Page 13: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/13.jpg)
Fast Conduction PathSlow Recovery
Slow Conduction PathFast Recovery
Premature Beat Impulse
Cardiac Conduction
Tissue
1. An arrhythmia is triggered by a premature beat
2. The beat cannot gain entry into the fast conducting pathway because of its long refractory period and therefore travels down the slow conducting pathway only
Repolarizing Tissue (long refractory period)
The “Re-Entry” Mechanism of Ectopic Beats & Rhythms.
![Page 14: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/14.jpg)
3. The wave of excitation from the premature beat arrives at the distal end of the fast conducting pathway, which has now recovered and therefore travels retrogradely (backwards) up the fast pathway
Fast Conduction PathSlow Recovery
Slow Conduction PathFast Recovery
Cardiac Conduction
Tissue
The “Re-Entry” Mechanism of Ectopic Beats & Rhythms.
![Page 15: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/15.jpg)
4. On arriving at the top of the fast pathway it finds the slow pathway has recovered and therefore the wave of excitation ‘re-enters’ the pathway and continues in a ‘circular’ movement. This creates the re-entry circuit
Fast Conduction PathSlow Recovery
Slow Conduction PathFast Recovery
Cardiac Conduction
Tissue
The “Re-Entry” Mechanism of Ectopic Beats & Rhythms.
![Page 16: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/16.jpg)
NCT WORKUPECGLab. Workup ( CBC,TFT,s.electrolyte,24 hour Holter monitorContinuous loop event recorderEchocardiogramTreadmill test ( with or after exercise)
![Page 17: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/17.jpg)
ALL ARE NARROW BUT THE DIFFERENCE IS WIDE
!!
![Page 18: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/18.jpg)
Tachycardias Arising From the Sinus Node Region
Sinus tachycardia and Inappropriate sinus tachycardia
Sinus node rentry tachycardia
![Page 19: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/19.jpg)
Sinus node reentry tachycardia
Sinus node reentry tachycardia arises from a reentrant circuit involving the sinus node, producing P waves that are fairly similar if not identical to those during sinus rhythm .
sinus node reentry can be initiated and terminated abruptly by a premature atrial stimulus, which is consistent with its reentrant mechanism. It is usually nonsustained and associated with slower rates than inappropriate sinus tachycardia, making it clinically insignificant.
Carotid sinus massage and other vagal maneuvers typically slow or terminate sinus node reentry.
![Page 20: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/20.jpg)
![Page 21: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/21.jpg)
![Page 22: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/22.jpg)
Inappropriate sinus tachycardiaIt is a clinical syndrome characterized by sinus tachycardia without an identifiable physiologic stimulus. Secondary causes for resting sinus tachycardia must be ruled out, such as anemia, hyperthyroidism, pheochromocytoma, and diabetes mellitus with autonomic dysfunction.
At least two clinical variants have been described: (1) resting heart rate of 100 beats/min or greater and (2) increased heart rate response to minimal exertion .Sinus rates greater than 200 beats/min are not characteristic of inappropriate sinus tachycardia, and paroxysmal increases in heart rate are not seen.
The mechanism of inappropriate sinus tachycardia is still speculative but is thought to be a primary abnormality of the sinus node complex characterized by a high intrinsic heart rate, beta-adrenergic hypersensitivity,
and accentuation by a depressed cardiovagal reflex.
![Page 23: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/23.jpg)
![Page 24: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/24.jpg)
Atrioventricular Node Reentrant Tachycardia
(AVNRT)
The most common form of paroxysmal SVT is AV node reentrant tachycardia (AVNRT), which accounts for greater than 60% of cases referred to an electrophysiology laboratory. Patients typically present in their 30s or 40s, with greater than 70% being women .Although the mechanism for AVNRT is reentry involving the AV node, the precise location of the reentrant circuit is uncertain but includes atrial tissue surrounding the AV node. The reentrant circuit consists of an anterograde limb and a retrograde limb.
![Page 25: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/25.jpg)
Types of AVNRTCommon (Slow – Fast).
Uncommon :
*Fast-Slow
*Slow-Slow
![Page 26: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/26.jpg)
![Page 27: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/27.jpg)
![Page 28: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/28.jpg)
Common AVNRT
![Page 29: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/29.jpg)
Uncommon AVNRT
![Page 30: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/30.jpg)
Atrioventricular Reentrant Tachycardia Mediated by Accessory Pathways.
The second most common form of paroxysmal SVT is AV
reentrant tachycardia (AVRT) using an accessory pathway
Accessory pathways are discrete bundles of myocardial tissue
bridging the atrium and ventricle along the tricuspid or mitral
valve annulus. More than half of accessory pathways are
situated in the left free wall, 20% to 30% occur in the
posteroseptal location, 10% to 20% occur in the right free wall,
and 5% to 10% occur in the anteroseptal location near the AV
node.
![Page 31: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/31.jpg)
Because the accessory pathway conducts more rapidly
than the normal conduction system, the ventricle is
producing a short P-R interval and a delta wave on the
surface ECG .
In contrast, about 25% of accessory pathways conduct
only retrogradely and are not manifest on the ECG
during sinus rhythm (Concealed accessory pathway).
![Page 32: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/32.jpg)
Orthodromic atrioventricular reentrant tachycardia
involving an accessory pathway,the tachycardia is narrow
complex because of anterograde conduction down the AV
node and His-Purkinje system. Retrograde atrial
activation over the accessory pathway results in a P wave
within the early ST segment .
![Page 33: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/33.jpg)
![Page 34: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/34.jpg)
![Page 35: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/35.jpg)
Ex.RT.Anteroseptal AP
![Page 36: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/36.jpg)
Atrial tachycardia is less common than AVNRT or AVRT,
accounting for fewer than 15% of patients referred for
electrophysiology study. It can occur in the pediatric
population, especially in children with surgically corrected
congenital heart disease. Atrial tachycardia usually arises from
a single localized atrial focus .
Atrial Tachycardia
![Page 37: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/37.jpg)
![Page 38: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/38.jpg)
![Page 39: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/39.jpg)
Atrial Tachycardia (3:2 & 2:1)
![Page 40: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/40.jpg)
Paroxysmal junctional reciprocating Tachycardia ( PJRT)
![Page 41: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/41.jpg)
Multifocal atrial tachycardia (MAT)
Multifocal atrial tachycardia is a rare SVT. It involves more than one atrial focus and requires at least three distinct P wave morphologies to be diagnosed on the surface ECG.
Because the foci fire independently of one another, the atrial rate is irregular and typically averages 100 beats/min. The P-R interval also may vary depending on the location of the foci relative to the AV node
The mechanism for multifocal atrial tachycardia has not been defined clearly but may be due to enhanced automaticity or triggered activity. Most patients with this arrhythmia have exacerbations of severe
underlying pulmonary disease with hypoxia.
![Page 42: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/42.jpg)
MAT
![Page 43: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/43.jpg)
Jnctional TachycardiaJunctional tachycardias arise from a discrete focus within the AV node or the His bundle. In the pediatric population, junctional tachycardia also is known as junctional ectopic tachycardia .
Junctional ectopic tachycardia presenting before 6 months of age usually is associated with underlying heart disease that carries a high mortality. In contrast, adult junctional tachycardia has a more benign prognosis and typically develops after the acute phase of myocardial infarction, digitalis intoxication, and acute myocarditis.
Although the precise mechanism for junctional tachycardia has not been defined, it is likely due to enhanced impulse initiation in the region of the AV node by automaticity or triggered activity rather than reentry
![Page 44: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/44.jpg)
Nonparoxysmal atrioventricular junctional tachycardia in a healthy young adult. Top, This tachycardia occurs at a fairly regular interval (“W-shaped” complexes) and is interrupted intermittently with sinus captures that produce functional right and left bundle branch blocks. Middle, Two P waves are indicated by arrowheads. The junctional discharge rate is approximately 120 beats/min (cycle length = 500 milliseconds) and the rhythm irregular, sometimes shortened by sinus captures or delayed by concealed conduction that resets and displaces the junctional focus. Bottom, Carotid sinus massage slows the junctional as well as the sinus discharge rates.
![Page 45: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/45.jpg)
Atrial Flutter
Atrial flutter is an atrial arrhythmia characterized by a regular rate, a uniform morphology, and a rate
greater than 240 beats/min. Atrial flutter is usually accompanied by a fixed 2:1 ventricular response,
and it is this rapid ventricular response that results in most symptoms. Atrial flutter may be observed
transiently after cardiac surgery or may persist for months to years. Many different forms of atrial
flutter exist, which has led to multiple classification schemes.
![Page 46: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/46.jpg)
Classification of atrial Flutter
Common (Typical)
- Isthmus dependant
- Non Isthmus dependant
Uncommon (Atypical)
![Page 47: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/47.jpg)
![Page 48: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/48.jpg)
Type I atrial flutter
![Page 49: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/49.jpg)
Type II atrial Flutter
![Page 50: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/50.jpg)
Atrial Fibrillation Atrial Fibrillation
Atrial fibrillation (AF) is the most common sustained cardiac rhythm disturbance occuring in approximately 0.4 to 1% of general population with increasing prevelance with age (10% over 80 years)AF may be:
Primary, no underlying disease Secondary to: HPT, IHD, MVD, …...
Increased MorbidityEmbolic complications (stroke)Reduced cardiac function; hemodynamic changesComplaints and symptomsIncreased mortality
![Page 51: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/51.jpg)
![Page 52: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/52.jpg)
Induction of atrial fibrillation by a premature atrial beat originating in the orifice of one of the pulmonary veins. These triggers can be caused by microreentrant circuits that occur in the transitional zone of cells as the pulmonary vein endothelium transitions into the left atrial endocardium
![Page 53: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/53.jpg)
The trigger for the induction of intermittent atrial fibrillation is located in the pulmonary veins in 90% of patients and outside the pulmonary vein area in 10% of patients
![Page 54: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/54.jpg)
![Page 55: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/55.jpg)
IT IS TOO WIDE HOW TO NARROW??
![Page 56: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/56.jpg)
![Page 57: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/57.jpg)
![Page 58: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/58.jpg)
![Page 59: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/59.jpg)
![Page 60: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/60.jpg)
Take home messege
Observe either the onest or the termination.
Note the P ,PR and RP.
Do vagal maneuver and adenosine.
![Page 61: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/61.jpg)
STILL VAGUE?EPS
![Page 62: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/62.jpg)
![Page 63: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/63.jpg)
Electrophysiologic study
HRA
HIS ds
HIS px
CSp
CSds
RVa
CS
RV
HRA HIS
Abl
![Page 64: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/64.jpg)
Ex. Concealed LLAP
![Page 65: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/65.jpg)
Ex.SA reentry
![Page 66: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/66.jpg)
Ex. PAF (RUPV)
![Page 67: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/67.jpg)
EX.Atrial tachycardia by CARTO (electroantomic mapping)
![Page 68: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/68.jpg)
HOW TO TREAT?
![Page 69: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/69.jpg)
Priority order: •Ca2+ Channel blocker• B-Blocker• Digoxin• DC cardioversion• Consider procainamide, amiodarone, sotalolPriority order:
• No DC cardioversion• Amiodarone• Diltiazem
• No DC cardioversion• Amiodarone
• No DC Cardioversion• Amiodarone• B-Blocker• Ca2+ channel blocker
• No DC cardioversion• Ca2+ channel blocker• B-Blocker• Amiodarone
• No DC cardioversion• Amiodarone• Diltiazem
Preserved
Preserved
Preserved
EF<40%, CHF
EF<40%, CHF
EF<40%, CHF
Junctional tachycardia
Paroxysmal supraventricular tachycardia
Ectopic or multifocal atrial tachycardia
Attempt therapeutic diagnosis maneuver• Vagal stimulation• Adenosine
Narrow-Complex SupraventricularTachycardia, Stable
![Page 70: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/70.jpg)
![Page 71: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/71.jpg)
![Page 72: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/72.jpg)
![Page 73: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/73.jpg)
![Page 74: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/74.jpg)
![Page 75: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/75.jpg)
![Page 76: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/76.jpg)
![Page 77: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/77.jpg)
![Page 78: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/78.jpg)
![Page 79: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/79.jpg)
![Page 80: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/80.jpg)
![Page 81: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/81.jpg)
Non Pharmacologic AF therapy
Catheter ablation.
Atrial pacing (single or dual site pacing).
Intraatrial ICD.
![Page 82: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/82.jpg)
![Page 83: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/83.jpg)
![Page 84: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/84.jpg)
AFFIRM TRIAL
![Page 85: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/85.jpg)
RACE TRIAL
![Page 86: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/86.jpg)
SPECIAL GROUP NEEDS SPECIAL TREATMENT
![Page 87: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/87.jpg)
![Page 88: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/88.jpg)
![Page 89: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/89.jpg)
WHAT IS COLOUR OF THIS TISSUE!!???
![Page 90: وقل ربى زدنى علما](https://reader036.fdocuments.us/reader036/viewer/2022070406/56814118550346895dace004/html5/thumbnails/90.jpg)
Thank You Thank You