Mild LV dysfunction Comments from Deep Chandh Raja and Chandrashekhar DD Long RP tachycardia P inverted in III aVL V6 ve in aVR terminally ve in V1 the activation starts low left ID: 935562
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Slide1
Young manIncessant tachycardiaMild LV dysfunction
Comments from Deep Chandh Raja and Chandrashekhar
Slide2D/D? Long RP tachycardia, P inverted in I/II/aVL/V6, +ve in aVR
, terminally +ve in V1- the activation starts low left atrial. AT vs atypical AVRT. With
Inj
Adenosine 6 mgm IV the tachycardia terminates after QRS; It does not help in the D/D
Slide3D/D at this stage? His-sync PVC not affecting the tachycardia- does not r/o AVNRT but eccentric
atrial activation; D/D- ORT using Left AP/AT. Sometimes in a left sided AP a His refractory VPD should be introduced from LV close to the AP to bring out pre-excitation of LA
Slide4Any value of this maneuver?
Yes; Variable VA timing revealed s/o AT. In AT there is no VA linking, i.e. the difference is > 10 ms.
300 ms
325 ms
Slide5Interpret. Diagnosis confirmed? Yes.
Here during VOP during the tachycardia, there is AV dissociation during the first 3 complexes, there is AV dissociation, ruling out AVRT. Then the atrial activation sequence changes. So it is an AT.
Slide6Adenosine 6 mg IV- comment. As before, tachy
terminates after a QRS. Prolongation of A-A CL, without AH prolongation, before termination: s/o adenosine sensitive AT
Slide7This is a useful open access article
Slide8Tachy induction- Spontaneous induction, first 4 complexes are atrial fusion. The are equal; the AA CL in CS12 has shortened from the 1
st AA interval, in CS910 from the 3rd AA interval and in HISP in the 4th AA interval- combined with adenosine termination, suggestive of triggered activity
VES during tachycardia- how does this help?
P wave morphology revealed post termination of V pacing
-/+
in V1
, -
ve
in I/II/
aVF
/
aVL
s/o infero-lateral mitral annulus.
The P wave onset coincides the the onset of the A in CS12.
Slide9RF signal- likely site? here the RFD signal looks good. The local A is earlier than others and is fragmented.
Tip unipolar signal would be very useful.
RF energy-
Successful termination.
Summary- Adenosine sensitive Mitral Annular AT (not only
perinodal
ATs but also
periannular
ATs are known to be adenosine sensitive)
30 ms
Slide10RF site- lateral mitral annulus.LAO 40 RAO 30
2 week follow up- no recurrence