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  • Virtual Program

    Saturday, June 6, 2020

    7 a.m. PT | 8 a.m. MT | 9 a.m. CT | 10 a.m. ET | 16:00 CEST

    17TH ANNUAL LEARN FROM THE EXPERTS: APPROACH TO THE UNKNOWN TRACING

    Course Director: George Klein, M.D. Faculty: William Stevenson, M.D

    David S. Frankel, M.D Moderator: Peter Leong-Sit, M.D.

  • Medtronic’s Medical Education programs are offered to provide attendees education on the FDA approved indications and use of our products.

    In the event a question is asked during the program that is not consistent with FDA approved product labeling, the Faculty has been provided guidance to inform the attendee that the question is an off-label use of the Medtronic product. A conversation may take place between the attendee and Faculty to address the question, but should not necessarily be considered endorsed by Medtronic.

    At any time, a question regarding a Medtronic product may be directed to Medtronic’s CRHF Office of Medical Affairs:

    CRHF Medical Affairs Manager Office: 877-359-6415 Email: rs.omacrhf@medtronic.com

    OFF-LABEL DISCLAIMER

  • DISCLAIMER This broadcast is provided for general educational purposes only and should not be considered the exclusive source for this type of information. The content will be shared with physicians and allied health professionals who seek a deeper understanding of the operation and use of Medtronic products and therapies with the intent of enhancing their knowledge of features and operations described in the clinician manuals. Patient information (names, serial numbers, date, etc.) has been changed or removed to protect the privacy of the patients referenced in this broadcast. At all times, it is the professional responsibility of the practitioner to exercise independent clinical judgment in a particular situation. Changes in a patient’s disease and/or medications may alter the efficacy of a device’s programmed parameters or related features and results may vary.

    COMPENSATION This faculty is being paid as a consultant for the services being provided in accordance with the Sunshine Act.

    CAUTION STATEMENT The content and case study data in this broadcast is provided by physician faculty and not all comments are the opinions of Medtronic.

    IMPORTANT REMINDER This information is intended only for users in markets where Medtronic products and therapies are approved or available for use as indicated within the respective product manuals. Content on specific Medtronic products and therapies is not intended for users in markets that do not have authorization for use.

    DISCLOSURES

  • Dr. George J. Klein Professor of Medicine University of Western Ontario London Ontario, Canada

    Financial: • Speaker Honoraria: Medtronic

    Disclaimers: • No conflict of interest • No relevant financial or nonfinancial relationships to disclose. • No discussion of off-label uses

    FACULTY DISCLOSURE

  • FACULTY DISCLAIMER

    Dr. William G Stevenson Professor of Medicine Vanderbilt Health Nashville, Tennessee

    • Financial Disclosures:

    • Honoraria:

    o Medtronic

    o Abbott

    o Biotronik

    o Boston Scientific

    o Johnson and Johnson

    • Consultant: Novartis

    • Intellectual Property: Patent for irrigated needle ablation consigned to Brigham Hospital

    • No discussion of off-label uses

  • FACULTY DISCLAIMER

    Dr. David Frankel Director, Cardiac Electrophysiology Fellowship Program Associate Professor of Medicine Hospital of the University of Pennsylvania Philadelphia, PA

    • Financial Disclosures:

    • Speaker/Honoraria: Medtronic

    • Consultant: Stryker

    • No discussion of off-label uses

    Virtual Course: Dr. Prystowsky’s 33rd Annual HRS “Interpreting the Unknown Electrogram”

  • Dr. Peter Leong-Sit Associate Professor University of Western Ontario London Ontario, Canada

    Financial: • Speaker Honoraria: Medtronic • Consulting, Speaker Honoraria: Baylis

    Disclaimers: • No conflict of interest • No relevant financial or nonfinancial relationships to disclose. • No discussion of off-label uses

    FACULTY DISCLOSURE

  • Holly Vitense, Susan Powell, Ashita Schafer, Babette Hubert , Cindy Holst, Rich Wawrzynski

    June 6 ,2020

    15th Annual Learn from the Experts: Approach to the Unknown Tracing …..Strategies for interpretation

    No disclosures , conflicts

    George Klein

    Dave Frankel

    Bill Stevenson

    Team Medtronic

    Peter Leong-Sit

  • Approach to the tracings….. Quick Scan…….

    • The starting point but it can be risky to make up your mind too early ….one tends to rationalize observations to fit initial notion

    Hypothesis testing • You need some tools….diff dx lists, fundamentals etc • Describe what you see looking at the whole tracing from ecg to egm…….don’t forget the

    ECG….. • Measure , don’t eyeball critical intervals • Focus on zones of transition or irregularity • Focus initially on zone that is understandable to you • Highlights are A to V relationship, atrial and ventricular activation sequence , His

    identification • Centre on a key observation and create a differential diagnosis i.e “frame” the problem • Test each hypothesis for “goodness of fit” …there is not always a “smoking gun”

  • Systematic ,Electrophysiological Approach..

    • Did you look at the WHOLE tracing ? Get some clues away from the “action”?

    • make up your mind too early ? • Fall into the trap of mechanistic jargon ? • Did you just “eyeball” important intervals? • Focus on specific zones ? • Miss a key observation ?

    If you got it wrong , ask yourself why ?

  • C/O ME JosephsonG.J. Klein

    Mechanism is : 1. Automaticity 2. Macrorentry

  • 26M presents with palpitations

  • Pacing RVOT during VT

    VT CL 445 440 420 400 380 Mechanism of VT : 1. Bundle branch re-entry 2. Scar related macrorentry 3. Focal

  • PVC in tachycardia

    1 AT 2 AVRT 3 AVNRT 4 JT 5 Need more data

  • VAV vs VAAV response

    • Mini tutorial

  • S S S

    500 ms

    I

    II

    III

    V1

    V5

    RA

    HBEd

    HBEm

    HBEp

    RVA

    Knight JACC 1999;33:775-81

    Retrograde Retrograde

  • Knight JACC 1999;33:775-81

    Retrograde Anterograde

    Last egm at pacing rate

  • SVT entrainment to refine mechanism…distinguish AVRT over septal AP from AVNRT

  • ∆VA 85 ∆PPI 115

  • Michaud et al. JACC 2001; 38:1163-7

    30 patients with atypical AVNRT, 44 patients with ORT using a septal AP

  • I

    V1

    Crista terminalis

    Circular

    mapping

    catheter

    Ablation

    Catheter

    Coronary sinus

    RAO LAO

    Lasso in LUPV Abl in LAap

    Pacing in LUPV ….. 1. Exit block 2. Entrance block 3. Neither 4. Need more data

  • Circumferential catheter in RUPV ,

    RUPV isolated ?: 1.yes 2. no 3. maybe

    The other side of the coin…….

  • 1,2

    5,6 9,10

    13,14

    17,18

    His

    1. AT 2 AVNRT 3. AVRT 4. Need more data

  • SVT at outside hospital

    Most likely : 1. AT 2.AVNRT 3.AVRT 4.JT 5.need more data

  • 1. AT 2. AVNRT 3. AVRT 4. Need more data

    I II

    III

    V1

    V5

    HRA RA mid RA low

    HIS

    CS p

    CSd

    RVA

  • 1. AT 2. AVNRT 3. AVRT 4. Need more data

    I II

    III

    V1

    V5

    HRA RA mid RA low

    HIS

    CS p

    CSd

    RVA

    RVA pacing is shown …..SVT continues. During pacing the V is dissociated from the A, excluding AV reentry and making AVNRT less likely. The p-wave after pacing is upright in II and isoelectric in III, not consistent with AV nodal reentry

  • I II III V1

    His d

    RVp

    RA V5

    His m

    His p

    RA

    Pacing at the RV apex during tachy.. 1. VT 2. SVT with aberrancy 3. Preexcited tachycardia 4. Need more data

  • 410 470 430 430 430

    1. VT 2. Preexcited AVRT

  • 1. VT 2. SVT with aberrancy 3. Preexcited tachycardia 4. Need more data

  • 1. VT 2. SVT with aberrancy 3. Preexcited tachycardia 4. Need more data

    Utility of tachycardia termination …..a ‘”transition point “

  • 1. AT 2 AVNRT 3. AVRT 4. Need more data

  • A transition

    1. LBBB to Normal SVT 2. SVT with bystander AP 3. VT to SVT

  • Post MI VT

    420

    12 3

    4

    Pacing site most likely : 1 2 3 4

  • I II III

    V1

    M ul

    ip ol

    ar ca

    th et

    er

    Abl d V5

    Abl p

    post infarct VT 12 3

    4

    Pacing site most likely : 1 2 3 4

  • M ul

    tie le

    ct ro

    de ca

    th et

    er

    Abl 1,2 Abl 3,4

    C 11,12

    B 5,6

    1

    2 3