41 yr old ladyRecurrent episodes of tachycardia

Sometimes terminated by deep breathing

Normal echo

Inputs from Ulhas Pandurangi

The features of the “GOOGLY” 1. Intermittent A-V Block

2. Long RP during 1:1 AV relationship

3. Inverted and narrow ‘P’ waves in inferior leads

4. VAV response on VOD

Hence “GOOGLY” seems to be Atypical AVNRT

( I wear Helmet, always, when Yash delivers)

Why should deep inspiration terminate tachycardia: The manoeuver - Muller is still mulling over

Normal ECG. PES (basal trainS1 + S2) from CS

Blocked His extrasystole

Tachy initiation- RV stimuli initiate tachy with 2:1 AV conduction, followed by 1:1 LBBB tachycardia – Atrial tachycardia or Atypical AVNRT

Atrial activation sequence during ventricular pacing is similar to that during tachycardia ? Atrial tachycardia originating near posteroseptal region or atypical AVNRT

Termination of LBBB, 1:1 AV tachycardia without ‘A’: AT or Atypical AVNRT

HIS PVC did not affect tachycardia – Does not help much

Very early PVC did not affect tachycardia – ORT unlikely

VAV response at the end of entraining VOD - AT ruled out, Atypical AVNRT ruled inAlso PPI-TCL more than 100 ms

300 ms425 ms

75 ms 250 ms

Easy inducibility by narrow QRS tachycardia by ventricular pacing – A clue for Atypical AVNRT, especially when P waves are inverted and narrow ( even in the presence of AV Block)

S2 initiated tachycardia Atrial activation sequence by S2 similar to that during tachycardia

The AV block is infra-His

Deep inspiration -2:1 to 1:1 AV conduction followed by termination during deep inspiration block in the retrograde slow pathway

Deep inspiration again- Vagally mediated tachy termination

Adenosine Both AH ( ) and HA ( ) prolong prior to termination in the retrograde limb.

RF site Activation mapping during tachy. A earliest in rfD

RF energy- Just above CS os. Tachy terminates retrogradely

After ablation – No VA conduction

Final diagnosis

Atypical AVNRT (Fast-slow for the “splitters”) with 2:1 AV conduction

Successful RF ablation of retrograde limb

No retrograde fast pathway conduction