This document contains an ECG report from the Department of Cardiology at JIPMER in Pondicherry, India. It describes the ECG findings of a patient who presented with narrow complex tachycardia and includes the results of an electrophysiological study and ablation. The EPS found the patient had atrial tachycardia originating from the left atrium posteriorly, and they underwent successful ablation. The document provides details of the case from initial ECG and symptoms to diagnosis and treatment.

1. Moderator
Dr Raja Selvarj
Presenter
Dr Praveen Gupta
Date-16.03.2017
JIPMER,
PONDICHERRY(INDIA)
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2. 2© 12/02/ 2017, Department of cardiology, JIPMER, Pondicherry, India: ALL RIGHT RESERVED

3.  Sinus rhythm at 84 beats per minute,
 PR interval 360 msec,
 Normal axis,
 Narrow QRS complex,
 No ST-T wave changes
 QT interval 360 msec,
 QTc-430 msec so the
 Ecg suggestive of first degree AV block
3© 12/02/ 2017, Department of cardiology, JIPMER, Pondicherry, India: ALL RIGHT RESERVED

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© 11/03/2017, Department of Cardiology, JIPMER, Pondicherry, India: ALL RIGHT RESERVED

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© 11/03/2017, Department of Cardiology, JIPMER, Pondicherry, India: ALL RIGHT RESERVED

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8.  Narrow complex, regular tachycardia
 Rate around 200 beats per minute
 P wave were not seen
 No significant ST-T wave changes seen
 There is no evidence of pre-excitation in the baseline ecg
 Diagnosis is Short RP tachycardia
 DD AVNRT.
 Final diangosis- Patient underwent EPS/ablation at JIPMER, Cardiology department.
EPS was suggestive of Atrial tachycardia with origin from left atrium, posterior in
origin. Patient underwent successful ablation.
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9. 9© 30/12/ 2016, Department of cardiology, JIPMER, Pondicherry, India: ALL RIGHT RESERVED

10. 10© 30/12/2016, Department of Cardiology, JIPMER, Pondicherry, India: ALL RIGHT RESERVED

11.  Tachycardia ECG-
 Regular narrow complex
tachycardia rate 200/minutes,
 LBBB morphology
 LAD
 QRS duration nearly 120 msec
 No AV dissociation,
 No P wave,
 No capture beat
 No fusion beat
 Sinus ECG
 Sinus rhythm at around 75 per
minute,
 LAD,
 No ST-T wave changes,
 No evidence of pre-excitaion
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12.  Patient underwent Electrophysiological study at Department of
Cardiology, JIPMER, Pondicherry, India, by Dr Raja Selvaraj and his
team.
 It was suggestive of Antidromic reentrant tachycardia
with mahaim accessory pathway. Patient underwent
successful radiofrequency ablation
 Final diagnosis is Mahim fiber tachycardia
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13.  The resting electrocardiogram (ECG) is usually normal
 No delta wave with Mahaim fiber conduction
 ECG features that suggest Mahaim fibers as the cause of a tachycardia
with a left bundle branch block pattern These include:
 QRS axis between 0 and minus 75º
 QRS duration of 0.15 seconds or less
 R-wave in lead 1
 rS complex in lead V1
 Precordial transition in lead V4 or later
 Cycle length between 220 and 450 milliseconds (heart rates of 130 to 270)
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http://www.uptodate.com/index

14. 14© 17/01/ 2017, Department of cardiology, JIPMER, Pondicherry, India: ALL RIGHT RESERVED

15.  Narrow complex tachycardia
 irregularly irregular
 No visible P wave seen
 Heart rate around 140 beats per minute
 ST segment depression with T wave inversion in lead II,III,avF, V4-V6
 ECG is suggestive of atrial fibrillation with fast
ventricular effect with digoxin effect
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© 23/01/2017, Department of cardiology, JIPMER, Pondicherry, India: ALL RIGHT RESERVED

17.  ECG-Sinus rhythm at 100/minute
 Inferior axis nearly 90 degree in view of equiphasic QRS in lead I
 Diffuse ST segment depression with T wave inversion in lead
I,II,III,avF,avL, V2-V6
 ST segment elevation in lead avR, V1
 PR interval 120 msec
 QT interval 360 msec
 QTc interval 464 msec
 The ECG suggestive of ACS/USA/ Most likely artery involved is
LMCA
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18. 18© 27/01/2017, Department of cardiology, JIPMER, Pondicherry, India: ALL RIGHT RESERVED
CAG, 27/01/2017(Pro no- 18538/ CD No-13338)-Right dominance, LMCA=Ostial 90-
95% stenosis, LAD=Ostial 70-80%,LCX= Ostial 70-80%, RCA=Moderte diffuse
diseases, max 60-70%. Diagnosis- CAD/TVD/LMCA Diseases.

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© 18/09/2016, Department of cardiology, JIPMER, Pondicherry, India: ALL RIGHT RESERVED

20. Description of the ECG
 Broad complex regular tachycardia at around 200 beats per minute
 Right axis deviation
 QRS duration around 280 msec
 RBBB morphology
 No P wave
 No capture wave
 No fusion beat
 Diagnosis-Broad complex tachycardia, Differential diagnosis- Ventricular tachycardia,
Or It could be Supraventricular tachycardia with aberrancy
Patient underwent EPS study and found to have Bundle branch reentrant tachycarida
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21. 21© 09/03/2017, With permission from RMMCH Hospital, Pondicherry, India: ALL RIGHT RESERVED

22. 22© 09/03/2017, With permission from RMMCH Hospital, Pondicherry, India: ALL RIGHT RESERVED

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© 09/03/2016, Department of cardiology, JIPMER, Pondicherry, India: ALL RIGHT RESERVED

24.  Description of the ECG-
 Broad complex regular tachycardia at heart rate around 190 beats per minute
 QRS of RBBB morphology
 QRS duration 240 msec
 Normal axis
 No capture beats
 No fusion beats
 No AV dissociation seen
 No visible P wave seen
 Negative concordance seen from lead V1-V6,
 rS seen in lead V6
 Final diagnosis- Ventricular tachycardia
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27. 27© 14/02/2017, Department of cardiology, JIPMER, Pondicherry, India: ALL RIGHT RESERVED

28.  Broad complex regular tachycardia with rate around 200 beats per minute,
 AV dissociation was present with intermittent visible P wave in lead I,II, V1.
 No capture beats
 No fusion beat seen
 Negative QRS concordance seen in lead V1-V5
 QRS complex were of LBBB morphology
 QRS axis being inferior (QRS complex are positive in lead II,III,avF)
 Diagnosis of this ECG is Ventricular tachycardia with inferior axis
 Final diagnosis if RVOT VT
 Cardiac MRI(14.02.2017)-Severe biventricular dysfunction, RVEF-25%, LVEF-22%,
RV free wall and sub tricuspid dyskinesia suggestive of Arrythmogenic right ventricular
cardiomyopathy
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29.  Identify the device on the right
side of the chest x-ray
 Its use?
 Its present status?
29
http://www.implantable-
device.com/wp-content/uploads/2011/12

30.  New innovative device therapy for HF
 Enhance left ventricular systolic function for
symptomatic patients, irrespective of QRS
duration
 80% of HF patients have a narrow QRS
 Implanting the pacing electrodes to superior
and inferior septum of right ventricle
 Pulse generator deliver large biphasic current
intermittently during the refractory phase of the
cardiac cycle so as to modulate myocardial
intracellular calcium.
 Intrinsic contractility of the left ventricle will
be enhanced
30
Chest X-ray of a patient who is a CRT non-responder and received CCM in
2009 (Optimizer III at that time). He has significant improvement of heart
failure symptoms from NYHA class IV to I. There was left ventricular
reverse remodeling and increase in ejection fraction. He is free of heart
failure rehospitalization in the past 4 years
Liu M, Fang F, Luo XX, Shlomo BH, Burkhoff D, Chan JY, Chan CP,
Cheung L, Rousso B, Gutterman D, Yu CM. Improvement of long-term
survival by cardiac contractility modulation in heart failure patients: A
case–control study. International journal of cardiology. 2016 Mar 1;206:122-
6.

31.  Improved HF symptoms and quality of life
 Left ventricular reverse remodeling
 Reduction of HF hospitalization and mortality
 Patients with ejection fraction between 20-40%
seems to benefit more than those with ejection
fraction <20%.
 Used in Europe and Hong Kong, China.
 FDA approval is underway
 Newest generation device (Optimizer IVis a
smaller device)
 CCM can be a treatment option for CRT
non-responders
31
©2017,CCM and Optimizer are trademarks of Impulse
Dynamics N.V. A Germany, Stuttgart
ALL RIGHT RESERVEDKwong JS, Sanderson JE, YU CM. Cardiac Contractility Modulation
for Heart Failure: A Meta‐Analysis of Randomized Controlled Trials.
Pacing and Clinical Electrophysiology. 2012 Sep 1;35(9):1111-8.

32.  Identify the foreign
body shown in x-ray
 Where it is used
 Advantage
32

33.  Smallest implantable cardiac monitoring device
 February 19, 2014 –Medtronic got U.S. Food and Drug
Administration (FDA) clearance
 80 percent smaller than other ICMs
 Allows continuously and wirelessly monitor patient's heart
for up to three years, with 20 percent more data memory
than its larger predecessor, Reveal® XT
 Provides remote monitoring through the Carelink® Network.
 Physicians notifications to alert them if their patients events
 Indicated for patients who experience symptoms such as
dizziness, palpitation, syncope (fainting) and chest pain that
may suggest a cardiac arrhythmia, and for patients at
increased risk for cardiac arrhythmias
 MR-Conditional, allowing patients to undergo magnetic
resonance imaging (MRI) if needed
33Medtronic Announces Global Launch of Miniature Cardiac Monitor, Reveal LINQ(TM) ICM
© 2014,MEDTRONIC,ALL RIGHT RESERVED

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