Finn Åkerström

⚡️New ELECTRICAL STORM paper out We propose the 5-stage STORM classification for electrical storm – a simple bedside scale that stratifies 30-day mortality from 5% to 50% and helps structure multidisciplinary care academic.oup.com/ehjacc/advance…

@mike_lean @danealson @_shannonmillard @AMatthews0 @Hapa_EP @javadm20 @Yogesh_EP @forkknifecab_EP @pjsm83 @ALFIEEP1 @hikmetyorgun @da_silvr @AbbottCardio I think both have there pros and cons. But it's very important with catheter contact, especially for NF. This is often not discussed!

Some post-case learning with @danealson (Dr. Neal Bhatia) and @_shannonmillard: following an ischemic VT case, together we compared how the clinical VT circuit presented when mapped with the First Deflection algorithm versus EnSite™ OT Near Field.   What we found brings up an interesting question. Is it better to…. - Force the system to visualize the full circuit with First Deflection, or - Illustrate the potential midmyocardial bridges and touchdown points with OT NF? While there may not be a "correct" answer, we think there is value in appreciating both pieces of information. And if nothing else, it makes for a fun discussion with talented colleagues like Dr. Bhatia and Shannon.

@Hapa_EP @mdjunkim @KhacThienChuong @pjsm83 @w04f40 @heartablator @SchakrabartiEP @GkhanAksan @javadm20 @CarinaHardy4 @forkknifecab_EP Both I'd guess!

@finnakerstrom @mdjunkim @KhacThienChuong @pjsm83 @w04f40 @heartablator @SchakrabartiEP @GkhanAksan @javadm20 @CarinaHardy4 @forkknifecab_EP Is this due to inadequate contact or is it something to do with the waveform on thicker tissue?

The pulmonary veins and posterior wall are isolated, but the patient is now in this atypical flutter 🪭. Which lesion set would you perform next? #EPeeps

@Hapa_EP @mdjunkim @KhacThienChuong @pjsm83 @w04f40 @heartablator @SchakrabartiEP @GkhanAksan @javadm20 @CarinaHardy4 @forkknifecab_EP I don't think Farapulse is suited for anything but pvi...

Some believe PFA can have a local cardioversion effect, but we got a satisfying termination ⚡ in the common isthmus nonetheless! The question is, should we continue this line down to the valve if mitral flutter cannot be induced afterwards or just leave it be? We left it be 😵‍💫

@hikmetyorgun Could you show us ILAM and voltage map pls?

Critical isthmus of VT is confined to small area despite extensive substrate! 👇 Epicardial map of ARVC demonstrating figure-of-8- reentry colocalized with DZ of ILAM. #EPeeps

Thank you all #Epeeps for joining us for a nice two-day course in complex AT/VT ablation at @KarolinskaUnsju. Special thanks to my co-facukty @Arritmias_HRC and Peter Jacobsen and to @AbbottCardio for organizing the course. Hope to see you next year!

@BozorgiAli I think the problem with this location is catheter instability due to dislodgement into the LAA if anterograde access is used. Do you agree?

⚡️ High left anterior AP 🛑 Often comes with a history of failed ablations. 📚 For EP fellows: If a left-sided AP 🔍 doesn’t merge with any CS poles → think of this rare high location 🎯. #EPeeps #CardioTwitter #MedEd #EPFellows

@ALFIEEP1 @SergioPinski Agree!

@finnakerstrom @SergioPinski I know your point but in this case is a long RP tachycardia. I haven’t seen a NF-AP in long RP tachycardia as part of the circuit. That should be a very unusual finding.

30yom Incessant tachycardia Left ventricular dysfunction. What would be the first pacing maneuver to make the diagnosis ? @hospitalposadas @LAHRSonline1

@SergioPinski @ALFIEEP1 I'd say that AA prolongation following his refractory pvc is pathognomonic of AP being an obligatory part of the circuit (in this case pjrt). With AA shortening (preexcitation), an atypical avnrt with bystander NF-AP is still a possibility? Atrial sequence would still be similar.

@ALFIEEP1 Excellent. At times one can see paradoxical delaying, which has the same diagnostic value.

@javadm20 I'd guess infero-anterior TA i.e. 7-8 o'clock. Can be v difficult ones!

Where is this PVC’s focus ; after a few hrs. ablation was failed! 🤔#Epeeps

@Hapa_EP @Arritmias_HRC @ftrae @KostekMilan @syamkumarmd @javadm20 @CarinaHardy4 @DrRoderickTung @adribaran @jogomezmd @jacabreracardio I agree with @javadm20 a out long lesions with good stability. At this site with good stability you can usually never go above 30w without steam pop. I have 3min as standard but did once a 5min application (suppression at 70sec).

That feeling of a one-burn ❤️‍🔥 termination during bigeminal LV summit PVC ablation! Although this time it took 11 long seconds for the PVC to suppress with RF just below the LCC. Does that mean the focus was just deep or were we not exactly on the right spot? #EPeeps #GridX

Excited to be part of the #EHRA_certification team! Setting standards & highly recommended to all (young) EPs in the field!

@Hapa_EP @syamkumarmd @capuzzi_luciano @guldencakir @javadm20 @SchakrabartiEP Hi, have some questions for you! Why did you do pwi and nothing about the ant scar (since you adopted some kind of substrate ablation strategy)? Why isolate svc?

As expected, flutter was easily terminated in the RSPV, but we opted to perform full PVI and PW isolation due to the diffuse atrial scarring. PFA 💥 made it super efficient!

Pinwheel 🎡 flutter in the RSPV before starting PFA PVI. Patient presented in this rhythm and ECGs going way back show only this AFL, sometimes 2:1 and sometimes Wenckebach. Do you isolate the RSPV and call it good, isolate both RPVs, or perform the full PVI as planned? #EPeeps

@brysontindal9 @JRWinterfield @AbbottCardio @BrysonTindal Looks like potentially difficult intramural isthmus!

@JRWinterfield @AbbottCardio @BrysonTindal Awesome case and ILAM map narrowing our ablation target. From being induced with singles to non-inducible at triples, great outcome.

Holiday weekend VT storms - case #1 of two with superb @AbbottCardio team @BrysonTindal - helped us map/ablate with combo venous EtOH and RFA complex 3D substrate in patient who underwent two ablations outside in past 2 months:

@MonicaKorzon @JuanBurnTerm => VoM

@JuanBurnTerm Ahhh yes - an Epicardial classic. Very cool. Thank you!

Hey #Epeeps! Zero-fluoro atypical flutter facilitated by the use of ICE and Contact index on EnsiteX 🎯 10 min Grid map demystified this dual loop flutter and identified a discreet shared low voltage isthmus on the lateral mitral annulus. One well placed #PFA application, guided by ICE and contact index, terminated the flutter and blocked the isthmus. PVI and PWI to follow 🧑‍⚕️ @vivasfhrs #MapMoreBurnLess #ContactMatters #OnlyonEnsite 💪 @AbbottCardio

@sozi81 @EPeeps_Bot Nice case, the PVC morphology looks more like inferoseptal process (r-wave in II) don't you think?

Nice #CruxCordis PVC inducing tachycardiomyopathy. CS mapping revealed the site of ablation ahead of mapping. PVC was intramural but RF 45W was enough to achieve complete suppression. Very nice uni and bipolar signal! #Niguarda @EPeeps_Bot

@Arritmias_HRC Might be a true 2D VT (the "black circuit")?

EPICARDIAL VT as a figure of 8‼️... previous inferolateral infarction. With Drs Moriña, Moraleda, Esteve y Carreño from Hospital JR Jiménez, Huelva.

@KostekMilan @jacabreracardio Attitudinal anatomy nomenclature makes everything easier to interpret for the EP: ECG, navigation systems, ICE...

The correct names for papillary muscles ❗supero-lateral and infero-medial ❗ LBB main trunk with three fascicles. Thank you, @jacabreracardio . (I'll explain the importance of this designation due to the live anatomic position in ECG hemiblocks later.) academic.oup.com/eurheartjsupp/…

#Epeeps, any suggestions on the mechanisms for this? Concealed anterograde/retrograde LBB conduction?

@Arritmias_HRC Nice. Sphere 9 is good for pwi but not for signal recording!

Paroxysmal AF in a young patient... still symptomatic months after PVI... no wonder... elicited reproducible posterior left atrium AF TRIGGER, recorded and terminated using Sphere-9 (Affera) 🤖 see 👇🧵