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Thanks.
PREOPERATIVE DIAGNOSIS: Wide Complex Tachycardia
POSTOPERATIVE DIAGNOSIS: Wide Complex Tachycardia
INDICATIONS FOR PROCEDURE: ...admitted to the inpatient service with a wide complex tachycardia around 115 beats per minute. She has a dual-chamber pacemaker in place.
DESCRIPTION OF PROCEDURE:
The patient is brought to the EP area for an EP study using her pacemaker.
She was set up for continuous vital blood pressure and oxygen saturation monitoring, as well as supplemental oxygen.
She had a continuous EKG running at the same time.
We used her pacemaker to perform an EP study.
We first interrogated her device. We performed threshold testing on her atrial and ventricular leads. Both leads tested stable in terms of sensing, pacing threshold and lead impedance.
We started with programmed extra-stimulus in the atrium.
RESULTS OF THE ATRIAL EXTRA-STIMULUS TESTING: We used a drivetrain of 600 msec starting with a single extra beat of 500 msec. On the third run, she had an easily induced rhythm at 115 beats per minute, consistent with the rhythm that brought her to the hospital. The rhythm was a perfect match morphological-wise to the 12-lead ECG of her presenting rhythm in the emergency room.
We then performed testing with pacing maneuvers during this rhythm. We paced the atrium and the ventricle. With ventricular pacing, we were able to entrain the atrial rate to the ventricular pacing rate. With atrial pacing, the rhythm would terminate and then spontaneously reinitiate.
We then reintroduced the SVT and gave her 6 mg of IV Adenosine, which produced complete AV block. During the AV block, she had a ventricular paced rate at 60 as per her device, but the atrial rate continued at 115 beats per minute, consistent with the tachycardia that we were inducing.
This was consistent with an ectopic atrial tachycardia at 115 beats per minute with a long A-V interval.
1. No evidence of ventricular tachycardia
2.Wide complex tachycardia, identical morphologic and rate to the rhythm that brought her to the hospital. Pacing maneuvers and Adenosine test confirmed that this is an atrial tachycardia with a long P-R interval. Interrogation of her device during this time is also consistent with an atrial tachycardia with a long P-R interval. Adenosine testing was used to confirm that is was a long A-V time and not a short VA time, such as AVNRT.
OVERALL SUMMARY: No ventricular tachycardia. Wide complex tachycardia easily induced pacing, and adenosine confirmed this to be an ectopic atrial tachycardia that conducts 1:1 from atrial to the ventricle with a long P-R interval. It conducts natively through her AV node with a wide QRS consistent with her baseline bundle branch block.
At this time we will leave her device programmed DDDR 70-130.
She is stable for discharge from the EP Lab.
Thanks.
PREOPERATIVE DIAGNOSIS: Wide Complex Tachycardia
POSTOPERATIVE DIAGNOSIS: Wide Complex Tachycardia
INDICATIONS FOR PROCEDURE: ...admitted to the inpatient service with a wide complex tachycardia around 115 beats per minute. She has a dual-chamber pacemaker in place.
DESCRIPTION OF PROCEDURE:
The patient is brought to the EP area for an EP study using her pacemaker.
She was set up for continuous vital blood pressure and oxygen saturation monitoring, as well as supplemental oxygen.
She had a continuous EKG running at the same time.
We used her pacemaker to perform an EP study.
We first interrogated her device. We performed threshold testing on her atrial and ventricular leads. Both leads tested stable in terms of sensing, pacing threshold and lead impedance.
We started with programmed extra-stimulus in the atrium.
RESULTS OF THE ATRIAL EXTRA-STIMULUS TESTING: We used a drivetrain of 600 msec starting with a single extra beat of 500 msec. On the third run, she had an easily induced rhythm at 115 beats per minute, consistent with the rhythm that brought her to the hospital. The rhythm was a perfect match morphological-wise to the 12-lead ECG of her presenting rhythm in the emergency room.
We then performed testing with pacing maneuvers during this rhythm. We paced the atrium and the ventricle. With ventricular pacing, we were able to entrain the atrial rate to the ventricular pacing rate. With atrial pacing, the rhythm would terminate and then spontaneously reinitiate.
We then reintroduced the SVT and gave her 6 mg of IV Adenosine, which produced complete AV block. During the AV block, she had a ventricular paced rate at 60 as per her device, but the atrial rate continued at 115 beats per minute, consistent with the tachycardia that we were inducing.
This was consistent with an ectopic atrial tachycardia at 115 beats per minute with a long A-V interval.
1. No evidence of ventricular tachycardia
2.Wide complex tachycardia, identical morphologic and rate to the rhythm that brought her to the hospital. Pacing maneuvers and Adenosine test confirmed that this is an atrial tachycardia with a long P-R interval. Interrogation of her device during this time is also consistent with an atrial tachycardia with a long P-R interval. Adenosine testing was used to confirm that is was a long A-V time and not a short VA time, such as AVNRT.
OVERALL SUMMARY: No ventricular tachycardia. Wide complex tachycardia easily induced pacing, and adenosine confirmed this to be an ectopic atrial tachycardia that conducts 1:1 from atrial to the ventricle with a long P-R interval. It conducts natively through her AV node with a wide QRS consistent with her baseline bundle branch block.
At this time we will leave her device programmed DDDR 70-130.
She is stable for discharge from the EP Lab.