1. 41 yr old lady Recurrent episodes of tachycardia Sometimes terminated by deep breathing Normal echo Inputs from Ulhas Pandurangi

2. 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

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

4. Blocked His extrasystole

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

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

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

8. HIS PVC did not affect tachycardia – Does not help much

9. Very early PVC did not affect tachycardia – ORT unlikely

10. VAV response at the end of entraining VOD - AT ruled out, Atypical AVNRT ruled in Also PPI-TCL more than 100 ms 300 ms 425 ms 75 ms 250 ms

11. 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)

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

13. The AV block is infra-His

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

15. Deep inspiration again- Vagally mediated tachy termination

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

17. RF site Activation mapping during tachy. A earliest in rfD

18. RF energy- Just above CS os. Tachy terminates retrogradely

19. After ablation – No VA conduction

20. 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