Comments from Deep Chandh Raja Chandrashekhar and Anunay Gupta Recent uneasiness with chest and shoulder discomfort Regular wide QRS tachycardia atypical RBBB morphology NW axis favors ID: 935387
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Slide1
77 yr old manOld CABG; severe LV dysfunction
Comments from Deep Chandh Raja, Chandrashekhar and Anunay Gupta
Slide2Recent uneasiness with chest and shoulder discomfort-
Regular wide QRS tachycardia- atypical RBBB morphology; NW axis favors VT. But note the initial q wave in aVR. During SVT-RBBB the initial rapid septal activation proceeds in a direction away from lead
aVR
, yielding an initial negative deflection.
Was in LVF; given DC shock
Slide3Tachycardia induced by ventricular
extrastimuli. Interpret.
Intrinsic QRS- q waves, notching in inferior leads suggest abnormal myocardial
substrate. Spontaneous PVC possibly of basal inferior LV septal
origin. VES is followed by sinus capture and then initiation of regular wide QRS tachycardia;
D/D- VT or SVT with atypical RBBB aberrancy
Possibly old
anteroseptal myocardial infarction. Frequent PVCs with
LBBB morphology with LAD, deep S in V5/V6 indicating that the exit is through the septum on the right
side, more towards the apex
Slide4Intracardiacs at induction- comment.
Following the last ventricular extrastimulus, the retrograde A goes down the slow pathway to the V and then up the fast pathway to produce a nodal echo beat that initiates an
A on V
tachycardia, probably typical AVNRT with RBBB
Next step
?
Maneuvers
during tachycardia- VOP,
differential ventricular
pacing during sinus rhythm/tachycardia
Slide5Post-VOP response. VAHV response s/o AV node dependent
tachycardia. AVNRT likely. Varying degree of RBBB and PVC (catheter induced) post VOP
Tachy
induced again- mode of induction
? With rapid
atrial
(CS) pacing @ 310 ms, PR>RR; on stopping pacing, slow-fast AVNRT is set up.
H
H H
H H
Slide6Any explanation for the changing QRS complexes?
Varying degree of RBBB aberrancy
Slide7This was seen later. NQRST into WQRST with positive HV interval
H
H
H
H H
Slide8Then VES induced this….
Wide QRS tachy with LBBB morphology; negative concordance tachycardia with V>>A s/o VT
Slide9Terminated
by VOP. How does one proceed from here? ATP should work for the patient First we should ablate the slow pathway to
get rid
of AVNRT
Slide10LAO views
The slow pathway was ablated Then a dual chamber ICD was implanted