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    ECG Challenge: Subtle but Significant



    Question 2 Answer: Recall that persistent, rapid AFL and AT, in addition to causing symptoms of palpitations, dyspnea, and fatigue, may lead to tachycardia-induced systolic heart failure. It is not uncommon for anti-arrhythmic drug therapy to be ineffective with left atrial arrhythmias, as in this patient’s arrhythmia which slowed to an average heart rate in the 90s-100s but nevertheless persisted despite attempted treatment with sotalol. She ultimately underwent electrophysiology study with 3-dimensional intracardiac activation mapping during ongoing tachycardia. Figure 3 displays the detailed electro-anatomic map of the anterior right atrial (RA-magenta) and posterior left atrial (LA- purple) chambers. A micro-reentrant AT was mapped to the RSPV, which is seen in the electro-anatomic map to traverse just posterior to the SA node at the RA-SVC junction.  Circumferential radiofrequency ablation around the RSPV (represented by light blue dots) terminated the tachycardia to sinus rhythm. Post-ablation, she has remained free of recurrent atrial arrhythmias.


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