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An electrophysiologist may find a procedure difficult because he or she is not familiar with the diagnostic or therapeutic maneuver needed to address an unusual, unexpected finding. However, perhaps the most challenging case we confront is the typical case, that is, one where we need to think simply without unnecessary complication with high expectation of success with ablation. The primary purpose of the series Teaching Rounds in Cardiac Electrophysiology is to present students of invasive electrophysiology and device management that bridge between these extremes and demonstrate the way an expert reasons in a straightforward manner but with the background plethora of multiple complex and involved possibilities.
See Article by Bagga et al
In this issue of Circulation: Arrhythmia and Electrophysiology, Bagga et al1 provide an outstanding example of how to combine practicality with erudition. They not only provide excellent teaching points and unique insights but openly showcase the problem of incomplete data and indeed explain how, despite the lack of an exact diagnosis, a successful outcome for their patient was enabled. The authors provide an elegant discussion of some of the cardinal rules and their exceptions when using diagnostic maneuvers to perturb an unknown circuit. A few of these principles are worth reemphasizing.
The Concept of Pseudointervals
We assume that the H-V interval is because of conduction traveling from the His bundle to a ventricular exit, and this interval represents the conduction time from the H to the V. However, in many instances such as during bundle branch reentry, the H-V interval represents a pseudointerval, that is, an interval created by the difference in conduction time from a common turnaround point (left bundle/distal His junction) to the recorded His and to the ventricular exit. Similarly, the H-A interval during atrioventricular node reentry or the H-V interval when both atrioventricular node conduction and …