80 yr old ladyNormal

Numerous episodes of palpitations (near-incessant) over many years, drug-refractory

Inputs from Chandrashekhar and Aditya Kapoor

As the EP procedure began…D/D?Long RP tachycardia, narrow P : Atypical AVNRT, Coumel (PJRT), AT arising close to CS OS

What next?Bring in His-refractory VPD and look for atrial advancement with reset/delay/tachy termination- indicates Coumel. Next do incremental V pacing at a rate 30 msecs faster than the tachycardia and look for VA dissociation. If VA conduction, after stopping V pacing look for the evidence of VAAV or VAV response VAAV response indicates an AT, VAV response indicates it may be either Atypical AVNRT or Coumel. Long VA: CS 7/8 and Hisp a bit early than

Tachy induction-commentInduction of a long RP tachycardia during CS pacing without any prolongation of the PR interval

Intracardiacs… A during tachy equally early at HIS and CS os (CS78-910).However, not much earlier than P wave onset

Analyse- VA conduction appears concentric, long VAERP

Adenosine-analyse. Prolongation of the AA interval prior to termination.

Terminates with a V: not very helpful…

Intracardiacs during adenosine- any further insight?Not really. A-V remains constant, the A-A and V-A prolong prior to termination.

Tachy mechanism?Not yet confirmed

Overdrive RV pacing during tachy, showing VA dissociation without affectingtachycardia cycle length.

Now AT confirmed!

Good signal to ablate? Yes: A early…unipolar goodLikely site?

RF site-LAO 40

RF site- RAO 30

RF energy- clean early termination.No tachy inducible after this

Energy starts here