Eric Lim

@murphy_lzy @Hapa_EP @sachinjv @forkknifecab_EP @JeffZhanghk2017 @Mya49099911 @AbbottCardio Choice of site to terminate this is pretty interesting. If ablating where indicated this should be near bachmanns. What are the possible consequences and how would you validate the ablation lesion? Curious to see post ablation map and the p wave morphology afterwards

Biatrial AFL type 2 “typical clockwise” AFL with trans-septal activation RA anterior septum - LA Bachmann’s bundle insertion point - LA middle septum- RA middle septum #AbbottEmp #epeeps @EricTSLim @Hapa_EP @sachinjv @forkknifecab_EP @JeffZhanghk2017 @Mya49099911 @AbbottCardio

@murphy_lzy @Hapa_EP @forkknifecab_EP @sachinjv @JeffZhanghk2017 @Mya49099911 I think I remember this case. It’s a nice case showing a lot of passive activation. I confess I don’t usually ablate potential circuits (exception being CTI) but seeing the left map I think I might try hard to induce a flutter and if it’s inducible, then choose to go after it.

Post TVR patient 1st time procedure: RA figure 8 reentry, no tachy induced after termination Pt came back after 7m with different flutter: encircled lateral vertical block line #AbbottEmp #epeeps #HDG @EricTSLim @Hapa_EP @forkknifecab_EP @sachinjv @JeffZhanghk2017 @Mya49099911

@PaCardiology How about this whopper? PR reaches 720ms. This guy can still exercise to stage 5 Bruce with 1:1 AV conduction!

@murphy_lzy @Hapa_EP @sachinjv @forkknifecab_EP @JeffZhanghk2017 @Mya49099911 @AbbottCardio I think CTI might work. Biatrial loop is the less common type where circuit goes from LA septum to RA free wall and back to CS. If there was a shorter route available it would tend to use that.

Biatrial AFL type 1 LA anteroposterior diameter 10cm Induced this nightmare after terminated 2 tachycardias #AbbottEmp #epeeps @EricTSLim @Hapa_EP @sachinjv @forkknifecab_EP @JeffZhanghk2017 @Mya49099911 @AbbottCardio

@rabinkova @murphy_lzy @sachinjv @Hapa_EP @JeffZhanghk2017 @Mya49099911 @AbbottCardio The mapping is limited by where you can get the wire. A vision wire or a normal PCI wire with a micro catheter to insulate it can be used. It’s less common to do this mapping in the arterial circulation I think.

@EricTSLim @murphy_lzy @sachinjv @Hapa_EP @JeffZhanghk2017 @Mya49099911 @AbbottCardio Wow. That’s a really interesting case! How were you able to wire map?

VT critical isthmus corresponds to one of the deceleration zones under RV pacing #epeeps #HDGrid @EricTSLim @sachinjv @Hapa_EP @JeffZhanghk2017 @Mya49099911 @AbbottCardio

@jeffrey_vinocur @murphy_lzy @rabinkova Actually for this case although we had used a Biotronik vision wire for the initial mapping, we changed to a PCI wire and used a micro catheter to insulate the prox portion. Indifferent electrode is in IVC. You can see good signals with it (white trace on pic).

@murphy_lzy @rabinkova Biotronik “VisionWire” is special because it is coated/insulated except the tip. With a regular metal wire may need to insulate shaft with a microcatheter?

@rabinkova It is a special guidewire with connection cable provided by Biotronik, but I am thinking normal guidewire plus alligator clip should work as well. The signals were unipolar, there was an indifferent electrode in IVC.

@murphy_lzy @sachinjv @Hapa_EP @JeffZhanghk2017 @Mya49099911 @AbbottCardio This was the septal VT from today, Murphy. No maps since we’d mapped it previously. First pic shows termination with cold saline in RPDA. Wire mapping shows concealed entrainment with TCL-PPI of zero. Coiling+gel foam in distal RPDA renders VT uninducible

Activation properties during sinus rhythm may be helpful for differentiating myocardial infarctions that are vulnerable for VT from those less vulnerable for VT #AHAjournals ow.ly/wIEj50wFMPn

@murphy_lzy @ericlim1975 @Hapa_EP @JeffZhanghk2017 @Mya49099911 @AbbottCardio Pretty interesting case. PVC somewhat pleomorphic and a little challenging to localise from the 12 lead. Very late potentials in SR which become precocious during PVC - sharp, almost Purkinje-like except I recorded it at lateral TV annulus. RF induced VT immediately.

PVC origin is a little bit far away from breakout. Challenging to have contact at the area. #epeeps #HDGrid @ericlim1975 @ericlim1975 @Hapa_EP @JeffZhanghk2017 @Mya49099911 @AbbottCardio

@murphy_lzy @ericlim1975 @Hapa_EP @JeffZhanghk2017 @Mya49099911 @AbbottCardio 4/ So despite the timing across the CTI you showed of 205ms, decreasing laterally, CTI is not actually blocked. If timing was taken more towards the IVC end, it would be a LOT shorter. Without an activation map and/or careful measurements it would be quite easy to make a mistake

@murphy_lzy @ericlim1975 @Hapa_EP @JeffZhanghk2017 @Mya49099911 @AbbottCardio 2/ But the activation map shows that there is an unusual pattern of activation where there is a gap at the IVC end of the CTI, *plus* a line of block causing activation to sweep laterally before turning in laterally. Hence the impression of block which is false.

It looks like unidirectional block from measurements. Used HD Grid to acquire a fast map, gap found! Is activation map essential for CTI line validation? #epeeps #HDGrid @EricTSLim @ericlim1975 @Hapa_EP @JeffZhanghk2017 @Mya49099911 @AbbottCardio

@murphy_lzy @ericlim1975 @Hapa_EP @JeffZhanghk2017 @Mya49099911 @AbbottCardio This propagation during CS pacing helps show it clearly. Black line indicates a line of block.

@murphy_lzy @ericlim1975 @Hapa_EP @JeffZhanghk2017 @Mya49099911 @AbbottCardio 1/ You don’t offer much explanation Murphy lol. Pretty sure this is my case. The measurements you posted (looking carefully at the map) show descending activation of the lateral wall. So CTI looks blocked.

@ecgwatford @narrowQRS @murphy_lzy @ericlim1975 @Hapa_EP @JeffZhanghk2017 @Mya49099911 @AbbottCardio From Demoulin and Kulbetus. Anatomical specimens of 20 normal hearts. What I take away from this is that there is a lot of variation but some kind of median or midseptal branch is quite common and can arise from the bi/trifurcation or as an early branch off a LAF or LPF

@EricTSLim @narrowQRS @murphy_lzy @ericlim1975 @Hapa_EP @JeffZhanghk2017 @Mya49099911 @AbbottCardio Does that map also show a septal fasicle?

ILVT with Dr Eric Lim🔥 Took a while to re-annotate P1P2 #epeeps #HDGrid @EricTSLim @ericlim1975 🔥@Hapa_EP @JeffZhanghk2017 @Mya49099911 @AbbottCardio

@murphy_lzy @ericlim1975 @Hapa_EP @JeffZhanghk2017 @Mya49099911 @AbbottCardio Would be good to have little more explanation, Murphy. RV pace map doesn’t just show an isochronally crowded / deceleration zone but there’s a putative channel there. That’s why Grid was placed there and extras used to stim+ induce VT with immediate mapping of diastole.

Sometimes VT is just like AVNRT. Our very first experience with HD Grid for ischemic VT case long long time ago #EPeeps #HDGrid @ericlim1975 🔥@Hapa_EP @JeffZhanghk2017 @Mya49099911 @AbbottCardio

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