Ziad F. Issa

#IssaTweeTorials is intended to provides bits of knowledge that can intrigue interest and increase appetite for more. Please provide feedback as you wish to help make this more meaningful.🙂

Just received the advanced copy of the new edition. It should be available by September 😊

@drvijaycardio Likely during HRS 2023 meeting.

A few people (actually just a couple) asked if I could start #IssaTweeTorials, to help extend basic and advanced EP knowledge to more EP MDs and fellows who may not be able to find time to read a book.

@pjsm83 @veramasloo @evgeny_lyan @PantlikRobert @ThomasDemming @KleinhansLukas @narrowQRS @PeterLeongSit AP potential (when present) is often presumed to be part of the A or V EGM. Therefore, it important to separate the components of the complex EGM (i.e., A, V, AP) that is usually recorded at the AP location. This often requires atrial/ventricular extrastimulation (see Figure).

#EPeeps Enjoy our new case with AVRT through concealed AP.Check out how OWM depends on the: 1⃣Direction of the slanted AP 2⃣Direction of the wavefront propagation (pacing site) Together with @evgeny_lyan @PantlikRobert @ThomasDemming @KleinhansLukas #EP_Bevensen #CardioTwitter

@KennethEllenbo1 I got to meet Santosh just recently. It took no more than a few minutes for us to become friends. The kindest soul ever. R.I.P. Santosh.

There are no words that capture the full depth of our sadness at the loss of our friend Santosh Padala. He passed yesterday from a cardiac arrest suffered during exercise. He was a fellow in 2014 and faculty in 2017. His enthusiasm was infectious. He will be missed by so many.

@szczasny @ftrae @soumd @UlhasDr @ecgrhythms @ecg_master @EcgImaging @smithECGBlog @narrowQRS Likely originating from inferior aspect of RVOT free wall.

40 yoF post cov19 palpitations any other comorbidities @ZiadIssaMD @ftrae @soumd @UlhasDr @ecgrhythms @ecg_master @EcgImaging @smithECGBlog @narrowQRS

@szczasny @UlhasDr @AboutRhythm @ecgrhythms @EM_RESUS Nice ECG. Focus is likely para-Hisian, left side of the septum, subvalvular.

SOO? @UlhasDr @AboutRhythm @ecgrhythms @ZiadIssaMD @EM_RESUS

9/9 Concealed transseptal conduction underlies aberration in several situations: 1) Perpetua­tion of aberrant conduction during tachyarrhythmias. 2) Unexpected persistence of acceleration-dependent aberration. 3) Alternation of aberration during atrial bigeminal rhythm.

8/9 Phase 4 block often follows a delay caused by a compensatory pause after a PAC or PVC, spontaneous slowing of the sinus rate, or overdrive suppression of sinus rhythm upon termination of a fast supraventricular rhythm.

#IssaTweetorials   What is the mechanism of aberrant conduction?   1/9 “Aberration” describes transient bundle branch block (BBB) and does not include persistent QRS abnormalities caused by persistent BBB, preexcitation, or the effect of drugs. #EPeeps #CardioTwitter #ECG

@mattaustein This has been my go-to approach for many years. It woks very well. pubmed.ncbi.nlm.nih.gov/17725755/

I had to do a thing for the first time today…

@jeffrey_vinocur @ALFIEEP1 @roberto_keegan @CarinaHardy4 @crpisani @Hapa_EP @DrRoderickTung @dr_pmueller I prefer more selective application of those techniques. Since the general region of the AP can be identified easily during routine activation mapping, progrmmed stimulation maneuvers are ofter cumbersome and not necessary to apply until the region of interest is identified.

@ZiadIssaMD @ALFIEEP1 @roberto_keegan @CarinaHardy4 @crpisani @Hapa_EP @DrRoderickTung @dr_pmueller I can’t find a tip-of-the-hat emoji but very nice What do you think about the pacing strategies that Jackman advocates to separate the EGMs widely for the entire period of mapping?

8 yom pt w/recurrent AVRT using a concealed AP. HD OWM w/HD grid showed a wide zone of VA conduction not defining the sweet spot. Detailed mapping w/ABL depicted the sweet spot off the ring close to the RAA ostium. Blue dots: His. #SanatorioSanMartin, Venado Tuerto, ARG.

@jeffrey_vinocur @ALFIEEP1 @roberto_keegan @CarinaHardy4 @crpisani @Hapa_EP @DrRoderickTung @dr_pmueller I routinely and methodically do these techniques (e.g., by extra-stimulation) in every case. I believe these maneuvers are necessary to verify which components represent A, V, or AP potentials, and also ensure that ablation target is at the appropriate aspect of the annulus.

@ZiadIssaMD @ALFIEEP1 @roberto_keegan @CarinaHardy4 @crpisani @Hapa_EP @DrRoderickTung @dr_pmueller How much effort do you routinely spend on maneuvers to separate A and V? Or selectively after initial mapping shows difficult-to/interpret EGMs?

@aspergian1 The delay btwn pacing stim and QRS is called “latency” and is caused by decreases myoc excitability due to reduced availability of Na-channels (Flecainide is Na-channel blocker). Latency can also be observed in hyperkalemia and during when pacing in diseases/scarred myocardium.

Learned something new! Sounds like an EP consult to me @ZiadIssaMD