Mike Manogue

@danealson presenting data on using upstream sinus electrograms to predict impending onset of VT/VF. Upstream sinus likely holds pathophysiologic insights to why arrhythmias occur and may open door to preventive strategies @experienceHRX @HRSonline @emoryheart @melchami99

@dredcronin @Marek_Jastrz_EP @MargaridaPujol @psharmadoc @OCanoPerez @GDandamudiMD @RChung_EP @MihailChelu Uni is my routine, but have wondered if I should change that given potential safety advantage of bipolar. NSLB capture is obligate even w uni configuration @ usual paced outputs. Septal anodal stim likely doesn’t effect LV synchrony, but will make qrs look different

#EPeeps when your LBBP patient is leaving the lab do you program unipolar or bipolar pacing, and why? @AveragingBogey @Marek_Jastrz_EP @MargaridaPujol @psharmadoc @OCanoPerez @GDandamudiMD @RChung_EP @MihailChelu

@PatelApoor @BurtchKatelyn That’s really nice, how tough was it to prolapse up into RVOT/PA? Use sheath?

Difficult RVOT PVC! Reverse U curve in pulmonic sinus junction led to termination. Next post has a great article that discusses pulmonic cusp PVC location based on imaging with ICE. #EPeeps #cardiotwitter @BurtchKatelyn

@EPDevinHiDefmap @JorgeI_Hernand LSPV was isolated with isolated firings throughout vein circumferentially

@AveragingBogey @JorgeI_Hernand Anything in the LSPV? Definitely picking up something from the Carina

#EPeeps Pulmonary vein EGM cornucopia. Prior surgical epicardial PVI (convergent), Orion in LIPV w three separate EGMs in the vein at once. An uncommon tracing in my experience. Map @JorgeI_Hernand

@MattMelcherPA @JorgeI_Hernand Agree w all that except I think 3 is near field from the ant LIPV, not FF. The unusual thing is that ant LIPV is isolated, posterior part of LIPV is still connected. Strange pattern you don’t often see in RF or cryo cases I feel like

@AveragingBogey @JorgeI_Hernand To me looks like: 1 = PV signal at posterior LIPV (B/C splines) 2 = FF LAA anteriorly (largest on F/G splines) 3 = FF Isolated fire from carina/LSPV (G/H spline)

@PatelApoor Very nice. For ablation did you approach directly from RA or loop catheter under TV?

Beautiful para-Hisian PVC from RV! Helpful to use what we know from LBB pacing morphologies in V1 to gauge para-Hisian PVC septal depth - see next post. #EPeeps

@ALFIEEP1 @hospitalposadas @GusCostaEP57 @KamilaOlivera13 Amen, beauty!

#WPW Left lateral AP Hello Kent…goodbye Kent EGMs is the ultimate sophistication above any mapping system. @hospitalposadas @GusCostaEP57 @KamilaOlivera13

@drjohnm Always the best way to start the day

Watts in the morning!

@EJSMD heartrhythmjournal.com/article/S1547-…

Hey #EPeeps -- Has anyone looked at efficacy of ATP therapy for VT delivered through LBBA pacing lead? Wondering if might be more efficatious than RV ATP as it can reach VT circuit excitable gap more quickly. We know conventional LV pacing lead ATP efficacy is limited by latency.

@joshuarutlandmd @krishpothineni @kevin_parrottMD @abhishek_mbbs @DrJasonAndrade @LuigiDiBiaseMD @DJ_Lakkireddy Don’t know about data for stopping it transiently like this, but seems reasonably safe in relative terms esp if surgery needs to happen quickly. Endothelialization in some people remains incomplete long after the implant. 5 day plavix pre-op hold should be enough??

#EPeeps @krishpothineni @kevin_parrottMD @abhishek_mbbs @DrJasonAndrade @AveragingBogey @LuigiDiBiaseMD @DJ_Lakkireddy 60d old WM FLX Pro, good seal @ 45d TEE, off AC & on DAPT now needing semi urgent surgery, any data on minimal wait time before 1-2 wk DAPT interruption?

@Arjun_K_T_15 Rhythmia

@AveragingBogey What mapping system is this?

Challenging CTI line, no block in spite of substantial effort. Pacing proxCS (star) gives this activation map from LAO caudal view. Red early,purple late. Where to target next? Answer ultimately in replies

@jeffrey_vinocur @XCosteas @mattaustein Agree, which is fine if it works but probably results in overablation in most cases

@XCosteas @mattaustein @AveragingBogey I think in most hands, those cases are either addressed with empiric creation of parallel lines until eventually block?

@XCosteas @mattaustein Would be much more difficult for sure. Possible, but quite difficult ina situation like this

@mattaustein @AveragingBogey Great work, thanks, but begs the question: how on earth can one detect remote sites of breakthrough without HD EAM mapping? Off topic: gorgeous Rhythmia screenshots.

@joshuarutlandmd Ultimately what happened best supported an obliquely oriented residual fiber that must have started at least somewhat endocardial on IVC side (at least enough to be bump terminated), then took an epicardial course in the lateral direction. Not likely a simple line breakthrough

@AveragingBogey Mike, why do you suppose the mapped showed early activation during CS pacing was lateral? I have seen this same thing, some terminate lateral with block suggesting epicardial connection and sometimes just a gap on the line.

@FindingSinus @mbelshazly Yeah I think that’s what it was here even though I couldn’t easily see it visually

@JRWinterfield Thanks!

@AveragingBogey Mike this is beautiful work. Thanks for sharing the tough flutter line. Fellows learn that if you understand flutter,you can understand EP.

@mbelshazly Always! I had my usual ICE here which I’d say didn’t show obvious band of muscle fiber that pointed to this region, but that’s where it was nonetheless.

@DavidRo67131019 Maybe, although on ICE it wasn’t really that big or prominent. Whatever the case had a little fiber/nook that apparently was easy to miss on the intial line creation

@AveragingBogey Huge Eustachian Ridge maybe?

Initial tweet sequence got screwed up. Here it is in proper, rational sequence.