Mildly dilated atria Comments from Deep Chandh Raja Aniruddha Vyas Chandrashekhar Anunay Gupta and Dipen Shah Comment Narrow complex tachycardia with flutter waves which ID: 933205
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Slide1
49 year old manIncessant palpitations since a few weeksMildly dilated atria
Comments from Deep Chandh Raja, Aniruddha Vyas, Chandrashekhar, Anunay Gupta and Dipen Shah
Slide2Comment. Narrow complex tachycardia with flutter waves, which are
broad-based: upright in lead V1, undulating (more +ve) in inferior leads. DD CW Flutter/ LA Flutter
Slide3Explain this and the next 2 traces.
Decapolar catheter in CS; Halo catheter in LA; Atrial flutter confirmed; 50% of CL confined within LA, therefore this is a LA atrial flutter; LA activation is roof to floor and inferior mitral annular activation is distal to proximal. Here the AA interval ( atrial flutter CL) varies
alternately.
PA
LAO 40
Slide4After 7 seconds- the CS catheter is in the same position.
All the CSEGMs are aligned vertically; maybe the proximal CS activation occurs because of conduction across the Bachmans bundle then along the septum to the CS os; activation also occurs along the CS from distal towards proximal, so activation occurs almost simultaneously in all the CS atrial
EGMs
Slide5After
another 12 seconds- the CS catheter is still in the same position. The CS activation pattern changes from distal proximal to simultaneous to proximal distal with changes in the morphology of EGM in CS channels, possibly suggesting changes in activation front of arrhythmia which activates the annulus. More than one flutter circuit or loops (would be more likely in scarred atria)
Slide6The underlying tachycardia is likely of LA origin since V1 is positive but the LA activation sequence shows irregularity – may be alternans
– with the CS in the opposite direction, so suggests CS-LA block except one connection distally. The subsequent slides shows a change in CS activation and this suggests activation through another LA-CS connection(s). Overall even though the surface ECG is suggestive of flutter, the LA recording shows significant variability and low voltage and suggests the likelihood of a fibrillatory substrate, typically with periods of organization alternating with fibrillation. The surface ECG can be very well organized because the RA is passively activated and the LA generates very low voltages.Unless you have biatrial
recordings, and preferably from large areas in both atria, you cannot reliably infer from limited recordings such as these. Changes in activation sequences in irregular rhythms usually imply areas of
fibrillatory
activity but dual loop and blind alley activation can still demonstrate abrupt sequence changes.