Two cases

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Raja Selvaraj, JIPMER

Case 1

Male with palpitations

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CS venogram

Mapping - lateral diverticulum

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Mapping - medial diverticulum

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Mapping - neck

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Mapping

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Mapping and ablation in CS diverticulum

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Raja Selvaraj et al. J Interv Card Electrophysiol 2016 Nov 11;47(2):253-259.

Learning points

  • Important to suspect diverticulum from ECG and look for it
  • Local V not as early as with AV pathways
  • Mapping strategy more like atriofascicular - target body of pathway than the insertion

Case 2

Presentation

  • 50 year old male
  • Recurrent palpitations since last ten years
  • Evaluation elsewhere 8 yrs back
    • Mild LV dysfunction / RBBB / no documented tachycardia
    • EP study - Inducible VT. Single chamber AICD implanted
  • Referred now on noting ERI

Course

  • On Amiodarone and beta blockers
  • Occasional episodes, treated with ATP
  • PG change done
  • Presented with VT storm 3 months after PG change

Evaluation

  • RBBB / LAD / normal PR on ECG
  • Hypokinetic IVS and RV apex, LVEF 47%
  • ICD - Sustained tachycardia at ~ 300 - 350 ms, ATP mostly successful

Regular WQRST in patient with RBBB / mild LV dysfunction

  • SVT
  • VT
  • BBRT

EPS - Baseline

  • RBBB, PR 150 ms
  • HV 46 ms
  • VAWB 540 ms
  • AVWB 360 , AVERP 600/280

Tachycardia at beginning of case with VA dissociation - Mapping strategy ?

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Mapping

  • Started activation mapping in RV, but VT terminated
  • Substrate mapping in RV
  • Low voltage, late potentials and fractionated EGM in basal septum, low septal RVOT

RV substrate map - What next ?

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Substrate based ablation

  • Ablated at all regions with abnormal EGM
  • Post ablation testing - VT inducible
  • What next ?

Activation map in RV - Double potentials on septum

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Diastolic potentials

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Double potentials

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Pacing from site

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Interpretation

  • Diatolic potential is far field
  • Captured electrogram is systolic
  • Manifest fusion
  • PPI = TCL + ~ 35
  • What do we do now ?

LV mapping - Double potentials on septum

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Pacing from site

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12 lead

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Ablation

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Learning points

  • Double potentials - Pacing to identify local vs far-field
  • Assimilate all info - PPI itself sometimes grey area
  • Septal sites - always consider substrate on other side