Kevin Brady

Atypical flutter on patient with prior PVI, anterior mitral line, and roof line. Where should we ablate? #EPeeps

@javadm20 @jacabreracardio @ftrae @Koichi16423232 @ecgrhythms @Maeskander @EF_Cardiaca @forkknifecab_EP @PVC_on_HERS @mike_lean Thank you Javad!! I agree 💯 %. Here is voltage (0.1-0.5 mV), but I only have PA view saved.

@Hapa_EP @jacabreracardio @ftrae @Koichi16423232 @ecgrhythms @Maeskander @EF_Cardiaca @forkknifecab_EP @PVC_on_HERS @mike_lean Great map Kevin as always! Please share voltage map as well if possible! Looks like ascending( PA) / left PV’s type of roof dependent flutter with possible LSPV reconnection!

Post PVI induced tachycardia. Ablation strategy? #EPeeps @Hapa_EP @mike_lean

@forkknifecab_EP @mike_lean Anteroseptal mitral line? Looks like double loop going around the right PVs and mitral annulus.

@Logan_Wynn @javadm20 @jacabreracardio @ftrae @Koichi16423232 @ecgrhythms @Maeskander @EF_Cardiaca @forkknifecab_EP @PVC_on_HERS @mike_lean Could be VoM involvement. Entrainment up at the top of the ridge and a bit further down the PW near the left carina were both in.

@Hapa_EP @javadm20 @jacabreracardio @ftrae @Koichi16423232 @ecgrhythms @Maeskander @EF_Cardiaca @forkknifecab_EP @PVC_on_HERS @mike_lean Vein of Marshall

@fvassallomd @javadm20 @jacabreracardio @ftrae @Koichi16423232 @ecgrhythms @Maeskander @EF_Cardiaca @forkknifecab_EP @PVC_on_HERS @mike_lean Agreed! 🤙 Thank you :)

@Hapa_EP @javadm20 @jacabreracardio @ftrae @Koichi16423232 @ecgrhythms @Maeskander @EF_Cardiaca @forkknifecab_EP @PVC_on_HERS @mike_lean Left superior PV with the prof scar. Beatifull maps

@KTamirisaMD @javadm20 @jacabreracardio @ftrae @Koichi16423232 @ecgrhythms @Maeskander @EF_Cardiaca @forkknifecab_EP @PVC_on_HERS @mike_lean Agreed! 💯

@Hapa_EP @javadm20 @jacabreracardio @ftrae @Koichi16423232 @ecgrhythms @Maeskander @EF_Cardiaca @forkknifecab_EP @PVC_on_HERS @mike_lean LUPV and extend to roof scar

EGM in the channel between the posterior LSPV line of block and scar patch on the roof.

And LAT map from the front and back

I saw that the original PVI ablation lines were very ostial. Even the LSPV in this case appeared partially stenosed. Patient also had a separate ablation procedure for a focal AT sometime after the PVI, from the anterior roof, which explains that scar patch. The 2 flutter lines were performed on a later case (possibly iatrogenic due to isthmi caused by the large scar patch).

@Hapa_EP @DFahadAlmehmadi @javadm20 @jacabreracardio @ftrae @Koichi16423232 @ecgrhythms @Maeskander @EF_Cardiaca @PVC_on_HERS @mike_lean All PV's in general appear to have been PVI'd versus WACA'd, antrum & carina spared, what was initial ablation strategy / modality?

@forkknifecab_EP @DFahadAlmehmadi @javadm20 @jacabreracardio @ftrae @Koichi16423232 @ecgrhythms @Maeskander @EF_Cardiaca @PVC_on_HERS @mike_lean Plenty of gaps for sure. Need to clean them all up after flutter termination. 👍

@Hapa_EP @DFahadAlmehmadi @javadm20 @jacabreracardio @ftrae @Koichi16423232 @ecgrhythms @Maeskander @EF_Cardiaca @PVC_on_HERS @mike_lean Need to address roof, and both anterior septal and anterior proper incomplete lines. There are many "reentry-welcoming" channels. SR or high septal pacing helpful to assess extent, pre / post ablation.

@forkknifecab_EP @DFahadAlmehmadi @javadm20 @jacabreracardio @ftrae @Koichi16423232 @ecgrhythms @Maeskander @EF_Cardiaca @PVC_on_HERS @mike_lean Low VID was set at 0.07 mV. LSPV egm had a delayed sharp second component, but I didn’t look closely at the egms in the posterior carina below the line of block in the posterior LSPV. Circuit could be going around that posterior line of block before the larger LPV wrap-around.

@Hapa_EP @DFahadAlmehmadi @javadm20 @jacabreracardio @ftrae @Koichi16423232 @ecgrhythms @Maeskander @EF_Cardiaca @PVC_on_HERS @mike_lean LIPV posterior carina looks sus, is there perhaps a small breakout prior to the larger LPV wrap around. What is LVID, do we have EGM in that area? Agree LSPV posteriorly looks isolated, with Peak Frequency Near Field applied, do we classify as farfield?

@mike_lean @javadm20 @jacabreracardio @ftrae @Koichi16423232 @ecgrhythms @Maeskander @EF_Cardiaca @forkknifecab_EP @PVC_on_HERS Agreed! Line of block on the posterior LSPV and the circuit is going through the gap between the vein and the scar patch on the roof.

@Hapa_EP @javadm20 @jacabreracardio @ftrae @Koichi16423232 @ecgrhythms @Maeskander @EF_Cardiaca @forkknifecab_EP @PVC_on_HERS I think it’s blocked on the posterior side of the LSPV and this is roof flutter through the small channel on the roof.

@DFahadAlmehmadi @javadm20 @jacabreracardio @ftrae @Koichi16423232 @ecgrhythms @Maeskander @EF_Cardiaca @forkknifecab_EP @PVC_on_HERS @mike_lean I agree, that looks like the right spot to treat for this flutter. Any other spots from the LAT map you think we should ablate as well?

@Hapa_EP @javadm20 @jacabreracardio @ftrae @Koichi16423232 @ecgrhythms @Maeskander @EF_Cardiaca @forkknifecab_EP @PVC_on_HERS @mike_lean Isolate lupv and connect lupv to scar on the roof

Your diagnosis ?

ReVolt against the ordinary ⚡️ PVI + PWI + CTI with #Volt PFA

White electrodes ≠ bad lesions ✅ Abdul Parwani explains how small areas of contact in the carina or small veins still yield transmural ablation. #EPeeps #AFib #PVI #Ablation

PERSIST-PWI trial: Rationale and design of a multicenter randomized controlled trial comparing PVI alone with PVI + PWI using pulsed field ablation in patients with persistent atrial fibrillation, by @ya4643su and colleagues heartrhythmopen.com/article/S2666-…