Yes! Your first observation is the expected behavior. Your second observation is the unusual finding.
At the end of the trace is there a block in the AP too?🤔
If you measure the time between the two deflections on the atrial channel, I think it will be implausibly short (compared to the myocardial refractory period) to be a true atrial event
I think sinus with FFRW oversensing and a PVC?
#EPeeps fascinating adenosine response
Sharing work from our group, especially as we question paradigms of clinical screening for FH and elevated Lp(a): www.sciencedirect.com/science/arti...
It is turning out that standard risk factors like LDL cholesterol and clinical/family history may not be adequate.
Lead reversal exactly
But it’s not pseudofusion- it’s biventricular pacing with a beautifully narrow QRS
IMO: flat line in DII ➡️ RA/RL lead reversal, SR with pseudofusion beats
#EPeeps Cute variant on a common ECG issue
Pseudofusion
Remains the #1 missed EKG diagnosis. Which is why it was my very first telemetry tips topic!
youtu.be/BbLYOcgdPb0?...
#EPeeps It's not very exciting, but I see this get missed over and over. Less subtle repeat in the thread.
#ACHD
Do #EPeeps believe in AVNRT upper common pathway (block)?
This patient had:
1. AH jump
2. Septal VA < 80 ms
3. Concentric A during SVT
4. During RVP: (Stim-A)-(V-A) > 85 ms
5. During RVP: PPI-TCL > 115 ms
6. SVT terminated by RV burst pacing
7. Ablation in TOK rendered non-inducible
Arrhythmogenic cardiomyopathy, epicardial access. Pacing from ablator.
@narrowqrs.bsky.social @shah.md @jeffreyvinocur.bsky.social @danacjohnson.medsky.social
#EPeeps
2 hearts.
Mom?
Ecg tech?
#EPeeps This baby's ECG has one of my favorite findings
So here's the mind-bending part. The ventricular lead is two unipolar screw-in leads with a Y adapter. So then have we localized to the adapter?
I did not think of the tip migrating hypothesis. But they are chronic screw-in leads. Actually did not re-image but here is an old film
Those strips were from programmer and I agree signal dropout can occur. But we previously had VHR episodes capturing abnormal device behavior (third one is example of how normal paced beat appears on the ring channel; this is unipolar pacing).
My best idea is intermittent short between tip and ring
#EPeeps Very unusual tracings from epicardial pacemaker - mirror noise all well and good, but has anyone seen bipolar go flat like this? Note carefully EGM configuration.
@narrowqrs.bsky.social
Exactly correct
Bilateral arm-leg reversal IMO
In line at coffee shop and silently cracking up randomly remembering the day somebody put hazelnut beans in the espresso machine
#EPeeps Don't see this so often!
#EPeeps Pacemaker patient reporting two weeks of fatigue
#IYKYK @narrowqrs.bsky.social
Such a convincing dot plot for a real pause and yet totally undersensing.
#EPeeps What do you think from the dot plot? Then see below.
Click BP tracing to expand.
What do you think the heart rhythm is before and after the transition?
#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.
#EPeeps I am strangely amused by this. Epicardial pacemaker with failing atrial lead, left in place as VVI backup in case of dislodgement of new transvenous system. "V sensing episode" corresponds to interrogation of new system:
