Abhinav Anand

#EPeeps My best trick for right anterior/anterolateral pathways is to use SR0, flex catheter until it points straight down, advance sheath to SVC-RA junction, and unflex onto the annulus.

You see the angle achieved in Fig 1…you have to take my word for the stability but often better than IJ access.

Tagging the masters.. @narrowqrs.bsky.social @jeffreyvinocur.bsky.social @shah.md @prashsanders.bsky.social @jkhmd.bsky.social @epsri.bsky.social @wsauer.bsky.social @sivamulpurumd.bsky.social

We hope that you enjoy reading this!!

SVT quest: The adventure diagnosing narrow QRS tachycardia The SVT mechanism includes atrial tachycardia (AT), orthodromic reciprocating tachycardia (ORT) via an atrioventricular accessory pathway (AP), nodoventricular pathway (NVP), nodofascicular pathway (...

Even though we ended up referencing Prof. Nagashima's another tour de force in the bibliography "SVT quest: The adventure diagnosing narrow QRS tachycardia" doi.org/10.1002/joa3... .
Both of these are excellent papers and should be read by everyone, I feel.

This is an excellent paper for understanding antegrade His capture and it's difference from retrograde His capture.

2. Novel Diagnostic Observations of Nodoventricular/Nodofascicular Pathway-Related Orthodromic Reciprocating Tachycardia Differentiating From Atrioventricular Nodal Re-Entrant Tachycardia by nagashima et al. (Doi: 10.1016/j.jacep.2020.07.007)

AV Nodal‐His‐Purkinje Reentry: A Novel Form of Tachycardia AV Nodal-His-Purkinje Reentry. Introduction: Bundle branch reentry (BBR) typically occurs in patients with dilated cardiomyopathy and infra-Hisian conduction system disease. The macroreentrant circui...

The proximal pivot is same in both the tachycardias (av node : nh cells). How our case differed was because of the distal pivot proximal to the bifurcation of the bundle branches resulting in a narrow complex tachycardia. ( doi.org/10.1111/j.15...)

1. A novel form of tachycardia: av node - his purkinje reentry tachycardia by markowitz et al. in 1995.

Finally two papers that were indispensable to writing this report.

A lot of the egms had to be shifted to the supplementary material due to journal restrictions.

We describe a case with longitudinal dissociation in the His bundle and how various maneuvers/ adenosine were used to make a diagnosis of av node-intrahisian reentry tachycardia.

“A on V” tachycardia in a patient with diseased His bundle We present a case of narrow complex, near simultaneous “A on V” tachycardia in a patient with diseased His bundle (intrahisian delay:35 ms; HV: 72 ms) and describe response to adenosine, RV overdrive...

Presenting a rare case of "a on v" tachycardia in a patient with diseased His bundle. (doi.org/10.1002/joa3...)

Looking forward to. Great tracing.
Thanks for posting. ❤️

Yes!!!
Was this patient taken for ep study?

So... during the double fire, the slow pathway causes concealed conduction in the fast pathway leading to blocked p wave (yellow)?

Nice.👌

SR, 1:1 avc
Pvc, parahisian(Narrow, 2,3 discordance)
PR suddenly prolongs. Likely due to a premature His complex causing concealed conduction and shift in the conduction from the fast to the slow pathway.
Conduction continues through the slow pathway due to retrograde fast pathway invasion.

That being said.
A few q.
1. Did you map retrograde through the aorta at the ncc also?
2. What is the risk of pacemaker that you explained for this pt?

Nice case!
I was thinking more lateral of the tricuspid annulus because of 2, 3 discordance. But just realised on reviewing the sinus ecg that the same discordance is present in the sinus rhythm as well.

TA 8-10 o ⏰

This is brilliant!
May I ask what is the software you use for making these?

Great case!
Thanks for sharing.

That being said.. most of the flecainide toxicity that I have seen have presented with qrs widening/ mmvt. So I may be biased that way.
Thank you for your comments.

This ecg has a few other differentials.
1.Hyperkalemia (addition of aldactone/aki)
2. Drug interaction causing increase in antiarrhythmic concentration.
3. Induction of epicardial vt due to biv pacing (less likely because of the spikes followed by qrs)

I think it's more appropriate to say that flecainide is contraindicated in patients with past mi rather than structural heart disease, since we have reports of the use of drugs in MVP with good results.
There's a spike followed by qrs, so this is still a paced rhythm rather than mmvt (1/2)

VAD with v>a.
Junctional tachycardia. (Given the clinical scenario)

Agree, totally!
Esp for an elderly.

Flecainide?