Prashant Bhave

Cardiac Electrophysiologist

[Prashant Bhave @PrashantBhave11]

@supadhyaymd @GeorgeBodziock @WFCardiology At EPS he had a L sided AP and easily induced ORT. Here's the EGM of ORT initiation and fluoro of successful site.

[Prashant Bhave @PrashantBhave11]

38 yo male with recurrent palps.
Thoughts on the likely etiology of this tachycardia? #EPeeps

[Prashant Bhave @PrashantBhave11]

@supadhyaymd @GeorgeBodziock @WFCardiology Great thoughts - totally agree. WCT transitions into slightly faster NCT. DDx includes VT initiating PSVT vs SVT with aberrancy that then peels back, narrows, and speeds up. If its all SVT, tachycardia getting faster with resolution of BBB strongly suggests ORT (Coumel's sign).

[Prashant Bhave @PrashantBhave11]

@WFCardiology @GeorgeBodziock Thanks for the responses! I thought a nice example of rate dependent LBBB (sinus rate slows slightly antecedent to QRS narrowing) giving us a look at T-wave changes due to memory. First described by Dr. Kanu Chatterjee in 1969!

[Prashant Bhave @PrashantBhave11]

Thoughts on this tracing? Explanation for the anterior precordial TWI? #EPeeps

[Prashant Bhave @PrashantBhave11]

@GangoliBorun @GeorgeBodziock @WFCardiology The ECG was read as AF (which is why she was referred to EP). P-waves are seen (ruling out AF) but the p-waves are not responsible for most of the narrow QRS complexes. The most likely diagnosis for this irregular narrow complex rhythm is an accelerated junctional rhythm.

[Prashant Bhave @PrashantBhave11]

28 yo female with exertion dyspnea and palps referred for abnormal rhythm. Thoughts on rhythm diagnosis?

[Prashant Bhave @PrashantBhave11]

@Van_Lav @GeorgeBodziock @WFCardiology Her EF is 40-45% and her exertional dyspnea is significant and getting worse. What would you do next?

[Prashant Bhave @PrashantBhave11]

@Van_Lav @GeorgeBodziock @WFCardiology Agree -- its not AF because there are clearly p-waves. But the p-wave before the 5th complex would not have time to create the QRS. So a diagnosis of junctional rhythm makes the most sense. Her Holter is shown here - incessant arrhythmia is noted.

[Prashant Bhave @PrashantBhave11]

@GeorgeBodziock @WFCardiology @DocBanks84 + delta wave in V1 indicates L sided AP (initial forces are toward V1, an anterior chest lead - this means that ventricular activation starts posterior [mitral annulus]). Will be important to counsel the patient that trans-septal or retroaortic mapping/ablation will be required.

[Prashant Bhave @PrashantBhave11]

Young patient, no medical history, presents with palpitations. Thoughts?

[Prashant Bhave @PrashantBhave11]

@GeorgeBodziock @WFCardiology You got it @DocBanks84 !
With pre-excited AF, you can do:
1. DCCV
2. procainamide
3. amiodarone

Need to avoid BB/CCB/adenosine.

Location of the AP based on this ECG? This will help you counsel the patient about risks of ablation.

[Prashant Bhave @PrashantBhave11]

@GeorgeBodziock @WFCardiology After the V-A-V response, the tachycardia continues. This rules out AT. The longer VA time during ATP as compared to the VA time during tachycardia suggests that the A and V are activated in parallel and not in series. In sum, this is most consistent with typical AVNRT.

[Prashant Bhave @PrashantBhave11]

Device EGMs from recent admit to hospital in a patient with CRT-D. Thoughts on DDx and likeliest rhythm diagnosis for the tachycardia? First EGM slide is immediately preceding second EGM slide.

[Prashant Bhave @PrashantBhave11]

@GeorgeBodziock @WFCardiology The end of the 1st panel (and into the 2nd) shows the device initiating ATP. The ventricular anti-tachycardia pacing advances the atrial rate to the rate of ventricular pacing, with a longer VA time than what was seen during tachycardia. When ATP is released, we see a V-A-V respo

[Prashant Bhave @PrashantBhave11]

@GeorgeBodziock @WFCardiology Nice answers!First panel shows a tachycardia with a 1:1 A:V relationship. V-A time is very short, making VT with 1:1 retrograde conduction (or ORT) unlikely but not impossible. AT is possible, although the consistent VA time (VA linking) makes this less likely.Likeliest is AVNRT.

[Prashant Bhave @PrashantBhave11]

@GeorgeBodziock @WFCardiology Nice observation that QRS morphology varies, which is likely due to subtle differences in depolarization between the junctional beats and the conducted beats.

[Prashant Bhave @PrashantBhave11]

next edition of the ECG challenge series:
tracing with machine read of AF with RVR.
your interpretation?

[Prashant Bhave @PrashantBhave11]

@GeorgeBodziock @WFCardiology Nice responses! My interpretation was: Accelerated junctional rhythm with JA conduction (P-waves are low-high ruling out sinus rhythm) which likely transitions from retroFast to retroSlow with the retroSlow beat echoing antegrade down the fast pathway.

[Prashant Bhave @PrashantBhave11]

@GeorgeBodziock @WFCardiology @JonathanRBrock @JNBlackwellMD @Taylor_Nipp @Scott_Rose_MD @DocBanks84 @AzizHamm0ud @Van_Lav @HarryHicklinMD Perfect answer — ECG shows that pre-excitation is gone and Twave memory is responsible for the inferior TWI. We expect Twave memory related ECG changes to resolve within several weeks.