PowerPoint Presentation

SPOTTERS (ECG,CXR,ECHO,EP) DR MAHENDRACARDIOLOGY, JIPMER

1.Case of ebstein s anomalyecg diagnosis?

Sinus rhythm at 70/minNormal axisTall and wide P wave with short PR intervalNegative delta wave in inferior 3,avfs/o right posteroseptal AP

RBBB present in 75-95% of caseVentricular preexcitation 5-25%.

2.50 yr old male c/o palpitation

Wide complex tachycardia with LBBB morphology with transient narrow complex regular tachycardia in betweenRate 150-160/minIrregularly irregularLeft axis deviationp/o- AF with abberancySvt due to preexcitation VT(less likely)

3

A coronary artery fistula -sizable communication between coronary artery, bypassing the myocardial capillary bed and entering either a chamber of the heart (coronary-cameral fistula)or any segment of the systemic or pulmonary circulation (coronary arteriovenous fistula).

4.A 70-year-old man with a history of coronary artery disease and an ischemic cardiomyopathy with a left ventricular ejection fraction of 38% presents to the emergency room with complaints of lightheadedness.

Sinus Rhythm with mobitz type 2 AV block

Regular Rhythm at a rate of 30 bpm. Left bundle-branch block morphology The axis is normal between 0 and +90 PR interval is 0.28 secondsMobitz type II high-degree atrioventricular block

5.Site of origin of these 2 rhythm ?

Atrial Rhythm @ 90 bpm, Negative P waves in inferior leads with 2:1 conduction.

1st Site Lower septum/ Tricuspid annulus

2nd Slide Right Pulmonary Veins

J.M. Tobis, I. Abudayyeh / Journal of Cardiology 65 (2015) 516Identify these 2 devices

Watchman left atrial appendage occluder Amplatzer cardiac plug.

Approximately 90% of emboli develop in the left atrial appendage due to stagnation of blood flow during atrial fibrillation .

Trans-catheter devices that occlude the left atrial appendage are attractive as an option to reduce the risk of emboli especially in patients intolerant of anticoagulation therapy or at an increased risk of bleeding

Watchman device is a self-expanding nitinol frame with fixation barbs and a permeable polyester fabric that covers the atrial side of the device 21 to 33 mm. Imaging and angiography should guide selection of the device size. After a trans-septal puncture, the device is delivered via a 12Fr catheter into the left atrial appendage. Trans-esophageal imaging is used during the procedure to ensure adequate fixation while covering the entire opening of the appendage.

Amplatzer cardiac plug (St. Jude Medical) is also a left atrial appendage-occluding device that is made from a flexible nitinol wire mesh.Device has a self-orienting disk on an articulating neck Distal part of the device occupies the left atrial appendage lobe for anchoring. The proximal articulating disk achieves full coverage of the appendage opening and is metaphorically termed the garbage can cover to the LAA. Device sizing depends on the distal inner-wall lobe and ranges from 16 to 30 mm.

7. Describe the ladder diagram

Gap physiology may affect conduction through the atrial myocardium and over the AV node. In Figure , extrastimulus (S2) delivered in the high right atrium arrives at the AV node (A2) when it is refractory (A lA2 < AVNERP )conduction is therefore blocked. In Figure 2.6a-iv, an earlier extrastimulus is delayed by latency and slowed conduction in the atrium. The propagated impulse now arrives at the AV node when the latter is no longer refractory (A1A2 > AVNERP), and is therefore conducted

The Gap PhenomenonPremature impulses fail to conduct but conduction resumes with even earlier premature extrastimuli.

Mechanism responsible - functional and effective refractory periods of the tissues involved.

The effective refractory period is the longest premature coupling interval during fixed rate pacing that fails to activate tissue. The functional refractory period is the shortest coupling interval that can result in conduction after delivery of premature extrastimuli during a fixed rate pacing.

8.M/12History of syncope while running Younger sister died of drowning at age of 10

8.Resting ECG prior to exercise stress testing

ECG during exercise stress testing

Resting ECG prior to exercise stress testing QT = 470msRR = 1.16sQTc = 440ms

NS Mok

Diagnostic criteria of LQTS

1 point low probability>1-3 points intermediate probability 3.5 points high probability of LQTS (revised 2006)Schwartz PJ 1993Schwartz Score

ECG during exercise stress testing QT = 340ms RR = 0.52sQTc = 470ms QTc prolonged by 30ms Suggesting LQT1 syndrome

9.ECG/ ORIGIN of 3rd beat marked with CIRCULATION

Regular rhythm at a rate of 84 bpm,Ventricular paced rhythm (VVI pacing), Retrograde P waves, Echo complex

Echo complexes may occur whenever the preceding QRS complex is not associated with a P wave. Junctional complex, ventricular complex or ventricular paced complex. As a result of VA conduction, the atria are stimulated and this atrial impulse can conduct through the AV node and His-Purkinje system to re stimulate the ventricles.

10.diagnosis?

non-sensing pacemaker has failed to sense the preceding native complexes, and is therefore not inhibited by them.

pacemaker will fire and stimulate the atria or ventricles at its own predetermined rate, independently of the intrinsic rhythm.

interval between the native and paced complexes is variable while the intervals of the pacing spikes is constant.

11.DIAGNOSIS?

Anterior STEMI equivalent2% of acute LAD occlusion.

12.Diagnosis?

TOF with right sided aortic arch

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