Ben Ng, MBBS, Robert W. Giles, MBBS, Zal Dastur, BSc, Mark A

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Flecainide-induced incessant orthodromic atrioventricular reentrant tachycardia in Wolff- Parkinson-White syndrome: Uneven depression of accessory pathway.

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Broad complex tachycardia in a patient with a pacemaker: What is the mechanism? Ben Ng, MBBS, Robert W. Giles, MBBS, Zal Dastur, BSc, Mark A. McGuire, MBBS, PhD HeartRhythm Case Reports Volume 4, Issue 6, Pages 232-236 (June 2018) DOI: 10.1016/j.hrcr.2018.02.005 Copyright © 2018 Heart Rhythm Society Terms and Conditions

Figure 1 A: Trace from the external defibrillator demonstrating a regular tachycardia of over 200 beats per minute, and successful 150 joule synchronized shock. B: Recording from the pacemaker of the clinical arrhythmia. No electrograms from the episode were stored or were available on interrogation. The strip demonstrates ventricular events exceeding atrial rates, suggesting a ventricular tachycardia. The atrial marker channels showed intermittent atrial events, detected within the refractory period. Note: Panels A and B are not on the same scale and are not concurrent. HeartRhythm Case Reports 2018 4, 232-236DOI: (10.1016/j.hrcr.2018.02.005) Copyright © 2018 Heart Rhythm Society Terms and Conditions

Figure 2 A: Intracardiac electrograms (EGMs) from high right atrial (HRA), His bundle, coronary sinus (CS), and right ventricular apex (RVa) catheters. Broad complex tachycardia with cycle length of 315 ms, with His bundle EGMs (arrow) preceding ventricular EGMs and HV interval of 65 ms. B: Intracardiac EGMs following administration of adenosine 18 mg, demonstrating atrioventricular dissociation with no perturbation of atrial rate. HeartRhythm Case Reports 2018 4, 232-236DOI: (10.1016/j.hrcr.2018.02.005) Copyright © 2018 Heart Rhythm Society Terms and Conditions

Figure 3 A: Device interrogation corresponding to Figure 2A at sweep speed of 25 mm/s with atrial electrograms (EGMs) displayed in addition to the marker channel, demonstrating 1:1 atrioventricular association but with no atrial sensed events and only 2 atrial refractory events displayed on the marker channel. The amplitude of atrial EGMs exceeded the programmed sensitivity of 0.5 mV, but events were not recorded because they fell within the post-ventricular atrial blanking (PVAB) period. B: Corresponding to Figure 3A, shaded boxes denote the PVAB period, with atrial events in the “A EGM” line marked AR (labeled with arrows) falling just outside the PVAB window. HeartRhythm Case Reports 2018 4, 232-236DOI: (10.1016/j.hrcr.2018.02.005) Copyright © 2018 Heart Rhythm Society Terms and Conditions