Gregory Michaud
@DrGregMichaud
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Beth Israel Deaconess Medical Center. Section Chief, Cardiac Electrophysiology
Boston, MA
Joined November 2017
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In the best Epsilon wave contest, this would be my entry...
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Can you make a diagnosis from this tele tracing? Woman with incessant tachy and severe CM
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Off the grid for a bit while moving back to Boston to join
@MGHMedicine
! Happy to join fantastic colleagues
@patrick_ellinor
@JagSinghMD
@MoussaMansour10
among many others.
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62 yo woman with unrepaired TV atresia, no RV, functionally 1 giant atrium. Giant circuit using "RA" then around mitral annulus, posterior LA and below mitral annulus back to the "RA". Line created from mitral annulus to the IVC.
#EPeeps
@EPeeps_Bot
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1. 75 yo man with 28 yo LAD infarct and endocardial ablation 8 years ago. Could induce clinical VT only from epicardium where entire circuit mapped. In fact, can see large part of CL on DecaNav. First lesion terminates. See thread for add'l maps (Thanks
@satouchtonjr
)
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RA flutter in 29 yo man with congenital AoV stenosis repair and azygos vein draining lower extremities. Great map by
@mike_lean
showing EGMs spanning entire protected corridor , a la
@DrRoderickTung
's VT maps. See reply for pacing response.
#EPeeps
@EPeeps_Bot
#EPfellows
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1. Woman with recurrent AT after PVI, Roof line, Anterior mitral line indicated by white stripe from MVA to RIPV (all intact). Biatrial circuit with RA-LA breakout via Bachmann's bundle and LA-RA via CS/post septum Note succ. lesion in RA.
#eppeeps
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Hey
#EPeeps
I’m a big boy now …………. DIPLOMA CERTIFICATE.
THIS CERTIFIES THAT
GREG MICHAUD, MD
has successfully ordered a cardiac MRI and refilled
metoprolol all by himself
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When we hear there was nothing we could do to fight Covid, consider that Japan has 126 million people and 326 Covid cases yesterday. We had 50K+!! They don't have a secret vaccine. They do simple, effective things, like mask wearing and social distancing. Infuriating....
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Speaking of fluoroless...putting up the ICE catheter and ...hello
#Eppeeps
!! Looks like he wants out of there with hands on the window! Got his wish 6 weeks ago. Mom and baby boy doing great after her L free wall AP ablation.
Mom gave permission to show
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Coherent map kinda cool. RA origin of AF with prior ablation. Circuit jumps from endo to epi, leaps over the brown patch before touching down again on endo. Transected the endo touchdown to terminate. Then intercaval line. Has full catheter MAZE now!
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#Epeeps
#Fellowsfirst
. SVT consult. Patient has not been to the EP lab and it is unlikely. What do you think the SVT mechanism might be? I put calipers on the 2nd tracing to make it easier (82 points is meaningless but represents the same "time" for each caliper).
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#epeeps
. Darn septopulmonary bundle! Before closing the gap in the inferior line of a single ring isolation, mapped the posterior LA and single lesion at site shown isolated the entire box (posterior LA and PVs).
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Exceptions to every rule. This turned out to be AVNRT!! 🤷♂️
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I love accessory pathway potentials
#epeeps
. Our fabulous
#EPFELLOW
@10HolmesDrop
with the uni-burn. Map a lot burn a little.
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Found this in my new office Interesting reading from Paul Dudley White who I am sure never had a Twitter account
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Happy to be at 25th
@AFSymposium
! Before hopping a plane, nice case of repaired TAPVR with ASD patch. "Rotor" on posterior septum. 3 lesions through this channel terminated AFL. Line completed SVC to IVC. Gray is dense scar. Thx
@tarrah_herrmann
for map
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SR activation through an inferior infarct scar. Somebody did a MAZE procedure on this guy's ventricle?
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Persistent AF on amiodarone. After full lesion set CV to SR. Rapid atrial burst pace induced sustained AFL. Unexpected, funny loop involving lower Crista. Abl in the gap converts to CTI flutter. Do
#epeeps
routinely look for AFL after restoring SR?
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Is this what the LA looks like in Australia?
#epeeps
@SaurabhkumarEp
@peterkistler3
@PrashSanders
@mike_lean
has a very active imagination!
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Based on the tracing below in a young man with congenital CHB, what do you think his 12 lead ECG looks like with DDD pacing?
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#Epeeps
and
#Epfellows
Join Sonny Jackman and me for a day sponsored by Biosense Webster. Sonny will do a deep dive into AVNRT and I'll present some tips as we walk through complex cases. See you in San Francisco!
Register here for free:
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#epeeps
Another tidbit before Fluoroscopy Reduction and Elimination Webinar 8/25-27with
@MRazminia
@paulzei
@DrRoderickTung
@srissundaram
Placement of Livewire with 6 cm spacing using CARTO
@tarrah_herrmann
. Easier than with fluoro!!
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#epeeps
One of the reasons I like double TSP for complex redo AT (post AF RFA). Pacing just below an anterior line shows a leak though the roof portion. Complicated conduction pattern!
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Anyone else finding performance reviews, annual disclosures and the usual mundane tasks particularly annoying right now
#epeeps
?
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#Epeeps
While reviewing a patient chart dug this up from ETT during dobutamine infusion (3 yrs ago!). No comment about the rhythm 😳. What is it and where does it come from?
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PVCs and VT from the MVA near the AMC "region". Signal from AIV was -40 ms but on the MVA nearly -80ms. Early signal very reproducible. Had PVC's on tele afterward but they turned off like a spigot after a few hours -- gone. How often do
#Epeeps
see a late effect with PVCs?
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Single ring redo case posted yesterday. Irregular AFL on anterior wall. Fractionation on C1D1 D1D2 on grid = 100 ms duration. Localized reentry will terminate in one or two burns at bullseye. No line since LAA would isolate with prior lateral mitral block. Not inducible.
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Explain the 2nd beat in V1, I can't really come up with a great explanation
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#epeeps
No, it's not atrial flutter north and south of the equator. Same patient, shared isthmus, both CW and CCW forms eliminated by connecting bottom of line of block (white stripe) to the TVA. Then a V pattern to the IVC to prevent CTI flutter. 😀😀
@tarrah_herrmann
for maps
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With friends
@JACCJournals
. Finally, my first tweet supervised by the Twitter muses
@DrRoderickTung
@Zo_EP2
@True_EP
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This patient admitted with severe bradycardia (unclear etiology). Normal ECG in 2020. EP team asked to place a temp-perm pacing wire. This short run is illuminating. Otherwise 100% paced as seen after the run. Complete AV block?
#Epeeps
#Fellowsfirst
#Residentsfirst
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Why is this a good... no, great place to burn this atypical RA flutter circuit. Entrained from ablation catheter tip. See blow up of circled area.
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Nice job
#Fellows
#Residents
. Starts with atrial flutter 2:1 AV conduction (flutter waves marked with arrows). The wider rhythm is NOT a multiple of the flutter cycle length which is marked by the short dash. First beat of 2nd tachy is fused. Therefore = VT, not aberration.
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Wow. Genetic testing back. X- linked mutation for Emery - Dreifuss muscular dystrophy. Very little muscular involvement. Didn’t think of that .....
22 yo in military with symptomatic bradycardia after intense exercise. BaselineJXL competing with sinus. EPS with extensive RA fibrosis and HV 75 ms. No VT inducible. MRI normal. No family Hx. Thoughts?
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As promised
#Epeeps
@rdschaller
.
@ogadeola1
got this on first try. Loop in RA with stylet back-> Push stylet forward as pull lead back slightly -> elbow first -> then lead tip. Usually lands in RVOT
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Can't resist da His. I know it's the 100th His ECG today on Twitter but.. kinda beautiful LBBB correction in man with LVEF 30%. Interestingly corrected at the His bundle area with threshold 0.5V/0.5 ms without screwing into the deep septum.
@DrRoderickTung
@Hisdoc1
#EPeeps
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#epeeps
.
@DrJasonAndrade
just finished a fantastic GR talk
@VUMC_heart
arguing for early ablation in patients with paroxysmal AF. He has contributed a lot to the field !
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Outside a London cafe. This about sums it up. The world is watching ... and wondering why we can’t follow simple preventive measures. We are so bad at prevention 😌
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72 yo woman with lung dz, recurrent persistent AF. Final lesion set wow! PVI w posterior LA. CS and lateral ridge w mitral line. CTI. Huge RA. RAA maintaining and reinitiating AF until isolated (PR catheter). Maybe RAA was enuf?
#EPeeps
@tarrah_herrmann
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Same Open WIndow Map of MidSeptal pathway in SR. (Less info this time 😳). Yellow dot is the His
#Epeeps
.
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64 yo man with 3 prior ablations for persistent AF. Extensive LA scarring! Eventually had AV junction ablation indicated below and AADs stopped. After 5 months became paroxysmal. Then almost nothing for year and a half. Seen this before, how about other
#EPEEPS
?
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@JorgeERomeroMD
@LuigiDiBiaseMD
@andreanatalemd
@DavidFBricenoMD
@isabellalviz
@dogi84md
@GrupposoVito
@josoriomd
@jfvilzalez
@HRSonline
@aalahmadmd
@JCardioEP
We have a paper about to be published by our great fellow Zach Yoneda in JACCEP that shows CTI performed in conjunction with AF ablation has a high rate of conduction leaks at redo. Probably a fatigue issue. At least if you do it, do it well.
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A real tweet for Halloween (groan)
#Epeeps
using the MiFi ablation catheter. Our great senior fellow Julia McHugh mapping with V pacing. Lovely accessory pathway potential seen on the mini-electrodes. Two left free wall APs in a week!
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27 yo man with 2 prior failed ablation attempts for "anteroseptal" AP. Now with syncope. A. Onset of pacing 500 ms. B. Ablation catheter at His bundle recording site. C. Pacing at His bundle recording site. What will be the outcome of AP ablation? Success at HB site?
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Little brainteaser. Unusual left mid-septal AP ablated. Now on isoproterenol with similar retro act seq. ParaHis pacing shown. RA electrodes lateral, Ablation sitting on septal MVA. How do you explain this reproducible finding?
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#epeeps
Redo for AFL. CTI & lateral mitral lines blocked. One RF in this gap site= PVs and posterior LA isolated. Single gaps in a ring don't cause AFL (in this case a localized circuit on the anterior LA). Is this an argument for why not to do single ring
@PrashSanders
? Discuss
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#epeeps
and
#epfellows
. What is going on? Gentleman with CAD, newly diagnosed LV dysfunction and SVT episodes.
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#Epeeps
. Single ventricle case with Frank Fish. Zero Flouro. Prior PVI and isolated posterior LA, leaky anterior line. Isthmus for AFL on septal ridge. Lateral mitral isthmus block after CS + lateral ridge ablation. Prior anterior mitral line not blocked. Final lesion set.
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#epeeps
. If native conduction is wider than the tachycardia, the origin is below the AVN and engages the HPS. Likely not BBRT since that is as wide or wider. Analogous to correcting LBBB by LBAP!!answer is VT
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One little P wave missing clinches it!! WCT with AV dissociation. = VT with rare exceprikns. The morphology suggests a left inferoapical septal exit and the sharp initial components indicate activation of the His Purkinje system. Probably Posterior Fascicular VT.
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How do you close a Watchman leak with a coil? Let Chris Ellis from
@VUMC_heart
moderated by
@CaraPellegrini
from
@UCSFHospitals
show you how On Demand
@HRSonline
2020.
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This is where the cryo lesion was placed. A lesion 3 mm more atrial caused AH delay and was terminated. V side was safe.
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#EPeeps
that is me! Old 🐕 new tricks. Will present short talk at Stanford a Biodesign tomorrow. See you at HRS!
That feeling when you have been working on something so long, and your peers think it is helpful and want to use it again...🥰
@sentiarco
@JonSilva_StL
@mksouthworth
@Berk_tash
@DrGregMichaud
@JagSinghMD
@JohnTriedmanMD
@WashUOTM
@WashUBME
@WashUPedsCard
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I think it explains why acute PVI is an unreliable surrogate for long term PVI. The PVs are susceptible to acute isolation from edema but recover. PFA is no exception although edema isn’t the likely culprit
@True_EP
@TheSteigasaurus
@JosefKautzner
Here is an example image from
@CRB_EP
and
@DrGregMichaud
: entrance block achieved with most of the back still open.
And in earlier work by
@VivekReddyMD
and Marc Miller: .
Edema will effect your lesion quality .
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#epeeps
#fellowsfirst
Another SVT consult with EP study by Mother Nature. Initiates with PVCs. Tele leads are II, V, aVR with low confidence. Calipers added for clarity
@ecgrhythms
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#Epeeps
...The Reveal!!! Why did I circle that EGM? Any guesses? I will post one tracing a day from this case until I get bored. There are many gems. 💎💎
RA deca across the TVA to pace septal RV, Pentaray at His recording site
Can you make a diagnosis from this tele tracing? Woman with incessant tachy and severe CM
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Welcome
@ep_travis
to the
#VUMC
EP faculty! All grown up! Welcome Seun Adeola and Asad Al Aboud to EP Fellowship. Great group we have.
@VandyRhythmdoc
@wgstevenson1
@VUMChealth
@VUMC_heart
#EPeeps
@jaymontgomery44
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#HRS
Board Review Course 2019 underway in Chicago. 160+ participants for initial certification or 10 year renewal. Intense 2 full days and 2 half days of lectures and workshops to prepare you for the exams .
@HRSonline
#EPeeps
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#Epeeps
What is this rhythm from a single chamber ICD? One tracing shows baseline EGMs and the other during tachycardia that received ATP and shocks. Baseline RBBB
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Bingo! With His capture, a shorter coupling interval to the AVN, causes "jump" from fast to slow pathway. Once in slow path, loss of His shows a more classic nodal response (end of trace). Like that one
@narrowQRS
@SergioPinski
? Pathway gone
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@ivanhbet
@blogarritmias
@CarinaHardy4
@finnakerstrom
@ManoloMolina8
@ajorozcog
@jvillacastin
@Ricardio81
@lalvaco
@DrBerruezo
@drrubenjuarez
@EPeeps_Bot
@JorgeToquero
There is a differential diagnosis: AVNRT, JT, or NF/NV. H-H prolongation following VA block favors AVNRT. Novel Diagnostic Observations of Nodoventricular/Nodofascicular Pathwa...
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I like
@Koichi16423232
explanation. Premature beat has short HV, probably ectopy from His catheter. Short VA time excl. AP (red arrow shows His A). Concealed retro conduction from catheter premature terminates AVNRT in FP (excludes AT). Other maneuvers excl. NF/NV.
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NICM and de novo left atrial flutter (bad sign) - propagation map shown. Ablation at choke point anterior to RPVs slowed circuit by 50 ms before a new flutter emerged 70 ms faster.
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This pic was used as an example of poor behavior in Ann Arbor, MI by the NYT (which I respect most of the time). Although maskless, these people are dining in pairs, outdoors, spaced apart. Couldn't this be used as an example of good behavior?
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22 yo in military with symptomatic bradycardia after intense exercise. BaselineJXL competing with sinus. EPS with extensive RA fibrosis and HV 75 ms. No VT inducible. MRI normal. No family Hx. Thoughts?
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The infamous Tung McGriddle sandwich
3D complete circuitry of ridge/VOM reentrant tachycardia. Yellow recorded within epi “sulcus” or “groove” and green on LSPV side of endo “ridge”. 🤝
@DrRyanBurris
@Noozie2
@ABeaser
@gauravaupadhyay
@DrGregMichaud
@MiguelVldrbno
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In case you wondered why Nashville needed a mandatory mask order in effect at 5 pm tonight...
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What is the mechanism of SVT
#Epeeps
? Deca in the RV (pacing from the tip) with 9,10 recording a septal A. ABL also recording a septal A. CS catheter tip in a posterolateral LV branch. Calipers on the CS A. More on this tomorrow🧐
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Most of you understood that block occurred in the His Purkinje system below the node. Clues are RBBB and short PR (AV nodal block usually long PR). Shorter PR after block is a pseudo interval from junctional escape giving appearance of Mobitz 1
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I don't think you can call this a long RP tachycardia because His/ RB precedes atrial activation i.e. the AH is long, not the HA. The HA or VA interval is too short for a typical accessory pathway. However, termination with His refractory PVC suggest concealed NF pathway.
Tracing challenge for fellows. Young pt with palpitations. Reproducible .What is the diagnosis?
#Epeeps
#Fellowsfirst
@NimaZamiri
@dog_oculus
@HeartShiv
@MartowMartow
@MaruanCarlos
@MattMelcherPA
@Doc_AleCuesta
@UlhasDr
@EPeeps_Bot
@Arritmias_HRC
@ALFIEEP1
@SignalstEPh
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@drjohnm
@PrashSanders
We have an absolute crisis in this country with obesity. No amount of encouragement from physicians will be enough to overcome this epidemic without a large scale effort that starts way before we see the patient.
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It was an excellent session and I encourage you to view when its available
#Epeeps
. .
We have recorded a great OnDemand session for
#HRS2022
@HRSonline
titled “challenging ablation cases and unusual approaches” The session was chaired by
@DrRoderickTung
and
@DrGregMichaud
I learned too much and I hope you will enjoy a lot
#VOM
abl
#CNA
and
#Summit
abl
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Arrhythmia smorgasbord. Typical atrial flutter (seen here), PVI for AF seen on pacemaker interrogations, PVC LBBB, transition V3 (aren't they all!) with inferior axis +I, - L and the answer is ...LVOT between R/L commissure (of course). BMI 42. Man..we need better diets!!
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I look forward to describing my approach to PV and posterior wall isolation in patients with persistent AF
Incor-Vandy Arrhythmia Conference tomorrow (4/29) at 5 pm central / 7 pm São Paulo. Come learn
@DrGregMichaud
's Approach to Persistent AF! DM
@crpisani
or
@JCook2035
for link/password.
@BenShoe57192092
@ep_travis
@VandyRhythmdoc
@cellisvandyep
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Pacing in the corridor shows non-propagated atrial capture (inferred). Captured tissue in the protected corridor fails to propagate to the atrium and is refractory to the next orthodromic wavefront. Afl reinitiated for the money shot of ablation term in less than a sec.
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68 yo with prior failed ablation. Retrograde conduction AVN, accessory pathway or both?
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#Epeeps
Like a bridge over troubled water🎶.. Multiple re-dos incl. ant and lat mitral lines. Discovered persistent left SVC (catheter in "VOM") acting as bridge. RF near distal end of CS cath terminated peri-mitral flutter and created block. Map by
@tarrah_hermann
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