Kevin Brady

@PennEPFellows The slow/late zones are where we place the catheter just before induction (Strategic Multi-electrode Positioning a la @DrRoderickTung ). More of a guesstimate of suspected isthmus locations where we can pacematch and immediately check for MDPs/perform entrainment after induction.

Sinus #ILAM propagation in a patient with prior anterior infarct, apical aneurysm, and apical morphology VT (12-lead ECG mysteriously vanished so I never saw it). Patient loaded up on amio/mexiletine and unable to induce VT during ablation. What do you do next? #EPeeps

@Hapa_EP Totally agree, but that’s arguing that VT induction with pace mapping and entrainment will change your ablation approach, not the deceleration zones. Again, it’s a debate here.

@PennEPFellows Had we been able to induce, we likely would have done more targeted ablation. Without pacematching, MDPs, or entrainment, we could not verify that targeting of the slow/late zones was enough, so we made the decision to homogenize a large area.

@Hapa_EP Constant debate here - did it change your approach to ablation? Looks like you did large substrate modification.

@chaturvedimd @DrFerminGarcia @B_Naz_MD @ftrae @jacabreracardio @Koichi16423232 @sozi81 @DrRoderickTung @ecgrhythms @NazemAkoum @PennEPFellows Sometimes when the latest part of the egm is very low amplitude, I have to dynamically lower the low VID setting down pretty far to get it to annotate correctly. I've gone as low as 0.05 mV. Otherwise if that doesn't work, I may have to do some manual annotation too.

@Hapa_EP @DrFerminGarcia @B_Naz_MD @ftrae @jacabreracardio @Koichi16423232 @sozi81 @DrRoderickTung @ecgrhythms @NazemAkoum @PennEPFellows Fantastic as always Kevin ! Your ILAM annotations of last deflections are spot on. Somehow when my tech does itz it invariably needs a LOT of manual reannotation. Can you please share your ILAM mapping settings? Thanjs

@outOfRAM @DrFerminGarcia @B_Naz_MD @ftrae @jacabreracardio @Koichi16423232 @sozi81 @DrRoderickTung @ecgrhythms @NazemAkoum @PennEPFellows Endo only on this one

@Hapa_EP @DrFerminGarcia @B_Naz_MD @ftrae @jacabreracardio @Koichi16423232 @sozi81 @DrRoderickTung @ecgrhythms @NazemAkoum @PennEPFellows Go epi?

In this case we performed full scar homogenization from mid-anterior LV to apex. If we could induce VT, we may have done less, looking for MDPs and entraining, possibly limiting ablation to decel zones, late pots, and high peak freq, but didn't want to leave anything to chance.

Peak frequency emphasis filter set at 350 Hz illuminating 🔆 areas of high frequency in low voltage (potential channels within scar). In the past I would often forget to use this, but I've been applying this feature more lately.

AV conduction system or Atrioventricular Bundle

As described by Wilber et al, in a subset of patients with inferior MI, "an isthmus of surviving tissue between the scar border and mitral annulus appears to constitute a critical region of slow conduction." This isthmus provides a target for VT ablation. doi.org/10.1161/01.CIR…

@EPsamurai1982 @adribaran @Arritmias_HRC @B_Naz_MD @DrFerminGarcia @ftrae @jacabreracardio @NazemAkoum @sozi81 @Zo_EP2 @DrRoderickTung Thank you Takayuki! Very happy with the results and the VT mapping techniques we have available to us!

@Hapa_EP @adribaran @Arritmias_HRC @B_Naz_MD @DrFerminGarcia @ftrae @jacabreracardio @NazemAkoum @sozi81 @Zo_EP2 @DrRoderickTung Congrats for your nice ablation strategy❗️

16 years old, VT or SVT? SOO?

So much interesting stuff happening around the valves

@atolat3 @adribaran @Arritmias_HRC @B_Naz_MD @DrFerminGarcia @ftrae @jacabreracardio @NazemAkoum @sozi81 @Zo_EP2 @DrRoderickTung This is true! I've seen a few of these as well, with a couple needing to go epicardial.

@Hapa_EP @adribaran @Arritmias_HRC @B_Naz_MD @DrFerminGarcia @ftrae @jacabreracardio @NazemAkoum @sozi81 @Zo_EP2 @DrRoderickTung Yes often seen in NICM as well 👍

@pzhong2016 @adribaran @Arritmias_HRC @B_Naz_MD @DrFerminGarcia @ftrae @jacabreracardio @NazemAkoum @sozi81 @Zo_EP2 @DrRoderickTung Thank you @pzhong2016! Patient doing well nearly a month later with no VT 😎, but we shall see!

@Hapa_EP @adribaran @Arritmias_HRC @B_Naz_MD @DrFerminGarcia @ftrae @jacabreracardio @NazemAkoum @sozi81 @Zo_EP2 @DrRoderickTung Great case.

@kevin_parrottMD @ECG_Emily @ecgrhythms @jeffrey_vinocur @Koichi16423232 @PennEPFellows @DrRoderickTung @Maeskander @jfreeMD @KostekMilan @B_Naz_MD Thank you! For inferobasal and septal scar, I've usually seen it be easier with transseptal access, especially to get good contact with ablator. For apical and lateral, retrograde seems to be the better bet, although I've seen it done both ways.

@Hapa_EP @ECG_Emily @ecgrhythms @jeffrey_vinocur @Koichi16423232 @PennEPFellows @DrRoderickTung @Maeskander @jfreeMD @KostekMilan @B_Naz_MD You make some really beautiful maps. Are you usually mapping retrograde or trans septal?

Where would you ablate? We ended up taking out the entire area between the scar and the inferior mitral annulus and were subsequently unable to reinduce VT afterwards with aggressive pacing. 😁

Diastolic potentials during VT within the isthmus. The patient's blood pressure did not tolerate tachycardia for very long, so we did not entrain and had to pace him out of it each time.