30 yr old man Normal echo 3 episodes of paroxysmal tachy All LBBB Inputs from Chandrashekhar,...
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Transcript of 30 yr old man Normal echo 3 episodes of paroxysmal tachy All LBBB Inputs from Chandrashekhar,...
![Page 1: 30 yr old man Normal echo 3 episodes of paroxysmal tachy All LBBB Inputs from Chandrashekhar, Chennai.](https://reader036.fdocuments.us/reader036/viewer/2022062722/56649f335503460f94c5089c/html5/thumbnails/1.jpg)
30 yr old manNormal echo
3 episodes of paroxysmal tachyAll LBBB
Inputs from Chandrashekhar, Chennai
![Page 2: 30 yr old man Normal echo 3 episodes of paroxysmal tachy All LBBB Inputs from Chandrashekhar, Chennai.](https://reader036.fdocuments.us/reader036/viewer/2022062722/56649f335503460f94c5089c/html5/thumbnails/2.jpg)
Analyse. Low atrial (CS) pacing. As CL decreases, there is gradual QRS widening resembling LBBB with LAD.
400 ms
![Page 3: 30 yr old man Normal echo 3 episodes of paroxysmal tachy All LBBB Inputs from Chandrashekhar, Chennai.](https://reader036.fdocuments.us/reader036/viewer/2022062722/56649f335503460f94c5089c/html5/thumbnails/3.jpg)
First is a sinus beat which shows His potential in the His D is earlier than the RB Potential in the RBP, which in turn is earlier than the RB potential in the RBD. Then pacing from HRAD starts (contrast with CS pacing in slide1), showing preexcitation. The wavefront goes down the right free wall pathway-- right atriofascicular pathway since it inserts distally into distal RBB So the RB potential from RBD now occurs earlier than the RB potential from RBP, which in turn occurs earlier than the His potential from His D indicating that the wavefront is going from below upwards
620 ms
![Page 4: 30 yr old man Normal echo 3 episodes of paroxysmal tachy All LBBB Inputs from Chandrashekhar, Chennai.](https://reader036.fdocuments.us/reader036/viewer/2022062722/56649f335503460f94c5089c/html5/thumbnails/4.jpg)
A pacing showing preexcitation; with atrial premature beat (S2)there is very slight increase in the preexcitation
![Page 5: 30 yr old man Normal echo 3 episodes of paroxysmal tachy All LBBB Inputs from Chandrashekhar, Chennai.](https://reader036.fdocuments.us/reader036/viewer/2022062722/56649f335503460f94c5089c/html5/thumbnails/5.jpg)
Any additional information? With V pacing and ventricular premature there is V3 phenomenon ( Bundle branch reentry)
![Page 6: 30 yr old man Normal echo 3 episodes of paroxysmal tachy All LBBB Inputs from Chandrashekhar, Chennai.](https://reader036.fdocuments.us/reader036/viewer/2022062722/56649f335503460f94c5089c/html5/thumbnails/6.jpg)
Now? No additional insight
![Page 7: 30 yr old man Normal echo 3 episodes of paroxysmal tachy All LBBB Inputs from Chandrashekhar, Chennai.](https://reader036.fdocuments.us/reader036/viewer/2022062722/56649f335503460f94c5089c/html5/thumbnails/7.jpg)
Diagnosis confirmed? Yes. Delayed RA APD after the septal A is committed preexcites the V indicating the presence of an AP and also resets the tachycardia, indicating the participation of the AP in the tachycardia circuit
![Page 8: 30 yr old man Normal echo 3 episodes of paroxysmal tachy All LBBB Inputs from Chandrashekhar, Chennai.](https://reader036.fdocuments.us/reader036/viewer/2022062722/56649f335503460f94c5089c/html5/thumbnails/8.jpg)
Again…The same
![Page 9: 30 yr old man Normal echo 3 episodes of paroxysmal tachy All LBBB Inputs from Chandrashekhar, Chennai.](https://reader036.fdocuments.us/reader036/viewer/2022062722/56649f335503460f94c5089c/html5/thumbnails/9.jpg)
And now? The tachycardia is terminated with an APD without conducting to the ventricle, indicating that the atrium is a component of the circuit
![Page 10: 30 yr old man Normal echo 3 episodes of paroxysmal tachy All LBBB Inputs from Chandrashekhar, Chennai.](https://reader036.fdocuments.us/reader036/viewer/2022062722/56649f335503460f94c5089c/html5/thumbnails/10.jpg)
Adenosine-commentTachycardia is terminated in the AV node
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Adenosine- commentNo preexcitation seen
![Page 12: 30 yr old man Normal echo 3 episodes of paroxysmal tachy All LBBB Inputs from Chandrashekhar, Chennai.](https://reader036.fdocuments.us/reader036/viewer/2022062722/56649f335503460f94c5089c/html5/thumbnails/12.jpg)
Any use of this manouever? Not really from the post-entrainment response point of view.However, one may induce retrograde right bundle branch block sometimes which results in
prolongation of the tachycardia cycle length
![Page 13: 30 yr old man Normal echo 3 episodes of paroxysmal tachy All LBBB Inputs from Chandrashekhar, Chennai.](https://reader036.fdocuments.us/reader036/viewer/2022062722/56649f335503460f94c5089c/html5/thumbnails/13.jpg)
LB with superior axis - Mahaim antidromic tachycardia
![Page 14: 30 yr old man Normal echo 3 episodes of paroxysmal tachy All LBBB Inputs from Chandrashekhar, Chennai.](https://reader036.fdocuments.us/reader036/viewer/2022062722/56649f335503460f94c5089c/html5/thumbnails/14.jpg)
Soon after- analyse. Preexcited A Fib intermittently (also seen in next slide)A rare ECG with Mahaim-like pathways
![Page 15: 30 yr old man Normal echo 3 episodes of paroxysmal tachy All LBBB Inputs from Chandrashekhar, Chennai.](https://reader036.fdocuments.us/reader036/viewer/2022062722/56649f335503460f94c5089c/html5/thumbnails/15.jpg)
During catheter positioning-interpret. Catheter bump.
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No Mahaim potential along tricuspid annulus
Mapping performed during atrial pacing and during tachycardia
What next?
To map more distally along the the atriofascicular pathway closer to the distal insertion site
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RF site- LAO 40
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RF site- RAO 30
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Signal at RF site
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RF energy
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As energy was continued, there was some automaticity of the heated RV site
After this, no preexcitation was seen with atrial pacing and no tachy was inducible