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.DModerator: Peter Leong-Sit, M.D.
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DISCLOSURES
Dr. George J. KleinProfessor of MedicineUniversity of Western Ontario LondonOntario, 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 StevensonProfessor of MedicineVanderbilt HealthNashville, 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 FrankelDirector, Cardiac Electrophysiology Fellowship Program Associate Professor of MedicineHospital 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-SitAssociate ProfessorUniversity of Western Ontario LondonOntario, 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 380Mechanism 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 LUPVAbl 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
5,69,10
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
III
III
V1
V5
HRARA midRA low
HIS
CS p
CSd
RVA
1. AT 2. AVNRT 3. AVRT 4. Need more data
III
III
V1
V5
HRARA midRA 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
IIIIIIV1
His d
RVp
RAV5
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
123
4
Pacing site most likely : 1 2 3 4
IIIIII
V1
Mul
ipol
arca
thet
er
Abl dV5
Abl p
post infarct VT 123
4
Pacing site most likely : 1 2 3 4
Mul
tiele
ctro
deca
thet
er
Abl 1,2Abl 3,4
C 11,12
B 5,6
1
23
4
Pacing site most likely : 1 2 3 4
I
II
III
V1
V5
Abl 1-2
Abl 2-3
Abl 3-4
Abl U-1
Abl U-2
His
RVA
1
23
4
Pacing site most likely : 1 2 3 4
Abl
Probability of ablation termination: 1. High 2. Moderate 3. Low
Sakthivel, Theodore, Selvaraj….PACE 2020
1. AT
2. AVNRT
3. AVRT
4. Need more
Ho R , HR 20091. AT 2. AVRT 3. AT 4. Need more
Ho R , HR 20091. AT 2. AVRT 3. AT 4. Need more
Confirms diagnosis : 1. YES 2. NO
Ho R , HR 2009
To verify mechanism , need : 1. entrainment 2. His refractory PVC 3.paraHisian pacing 4. No further testing needed
Mechanism : 1. AT 2. AVNRT 3. AVRT 4. Other/Need more data
1. AT 2. AVNRT 3. AVRT 4. Other/Need more data
Most likely: 1.Arrhythmogenic RV cardiomyopathy 2.Cardiac Sarcoidosis 3.Lamin A/C cardiomyopathy 4.Idiopathic VT
70Virtual Course: Dr. Prystowsky’s 33rd Annual HRS “Interpreting the Unknown Electrogram”
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