41 yr old lady Recurrent episodes of tachycardia Sometimes terminated by deep breathing Normal echo...

41 yr old ladyRecurrent episodes of tachycardia

Sometimes terminated by deep breathing

Normal echo

Inputs from Ulhas Pandurangi

The features of the “GOOGLY” 1. Intermittent A-V Block

2. Long RP during 1:1 AV relationship

3. Inverted and narrow ‘P’ waves in inferior leads

4. VAV response on VOD

Hence “GOOGLY” seems to be Atypical AVNRT

( I wear Helmet, always, when Yash delivers)

Why should deep inspiration terminate tachycardia: The manoeuver - Muller is still mulling over

Normal ECG. PES (basal trainS1 + S2) from CS

Blocked His extrasystole

Tachy initiation- RV stimuli initiate tachy with 2:1 AV conduction, followed by 1:1 LBBB tachycardia – Atrial tachycardia or Atypical AVNRT

Atrial activation sequence during ventricular pacing is similar to that during tachycardia ? Atrial tachycardia originating near posteroseptal region or atypical AVNRT

Termination of LBBB, 1:1 AV tachycardia without ‘A’: AT or Atypical AVNRT

HIS PVC did not affect tachycardia – Does not help much

Very early PVC did not affect tachycardia – ORT unlikely

VAV response at the end of entraining VOD - AT ruled out, Atypical AVNRT ruled inAlso PPI-TCL more than 100 ms

300 ms425 ms

75 ms 250 ms

Easy inducibility by narrow QRS tachycardia by ventricular pacing – A clue for Atypical AVNRT, especially when P waves are inverted and narrow ( even in the presence of AV Block)

S2 initiated tachycardia Atrial activation sequence by S2 similar to that during tachycardia

The AV block is infra-His

Deep inspiration -2:1 to 1:1 AV conduction followed by termination during deep inspiration block in the retrograde slow pathway

Deep inspiration again- Vagally mediated tachy termination

Adenosine Both AH ( ) and HA ( ) prolong prior to termination in the retrograde limb.

RF site Activation mapping during tachy. A earliest in rfD

RF energy- Just above CS os. Tachy terminates retrogradely

After ablation – No VA conduction

Final diagnosis

Atypical AVNRT (Fast-slow for the “splitters”) with 2:1 AV conduction

Successful RF ablation of retrograde limb

No retrograde fast pathway conduction