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Long RP & the chamber of secrets

Patient presentation

  • 53 year old female

  • recurrent palpitations

  • documented tachycardia on ECG
    -    narrow complex regular tachycardia with a long RP

  • adenosine sensitive

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Differential diagnosis

  • AVNRT (atypical)

  • AVRT

  • Junctional tachycardia

  • Atrial tachycardia

Baseline ECG/EGM

  • AH: 68

  • HV: 48

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Retrograde incremental pacing

  • Initially midline (CS 9,10)

  • change to eccentric retrograde atrial activation (earliest CS 1,2)

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Incremental atrial pacing

  • Decremental AV conduction

  • No evidence of pre-excitation

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Antegrade paced extras

  • AV decrement, no AH jump and tachycardia induced

  • 3 midline atrial beats (HIS A) which becomes eccentric (CS 1-2)

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Tachycardia

  • also initiated with ventricular paced extras

  • Narrow complex tachycardia

  • TCL 380ms

  • VA interval 122ms

  • eccentric atrial activation (CS 1,2)

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HIS synchronous VPB

  • No atrial advancement during HIS synchronous VPBs
    (nothing ruled out)

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Ventricular entrainment 

  • VAV response

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  • 1 beat to entrain the atrium

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Diagnosis

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Ablation

  • mapped to 1 o'clock on mitral annulus (superior LA)

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  • 28ms prior to CS

  • Gone in <2.5 seconds with ablation

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Post ablation

  • 2: VA conduction with fast ventricular pacing (midline atrial activation)

  • no other diagnostic tests performed 

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