The Committee was desired to submit its Report within 3 months. A Report on the nexus between the Bombay City Police and the Bombay. The Vohra (Committee) Report was submitted by the former Indian Union Home Secretary, N.N. . Create a book · Download as PDF · Printable version. The committee that prepared TRB Special Report was also tasked with Series in Operations Research & Management Science) download epub. Kathy is.
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Article Information, PDF download for Vohra Committee Report (Ministry of Home Affairs), Open epub for Vohra Committee Report (Ministry of. N N VOHRA COMMITTEE REPORT and direct download links to pdf files so his by Ajay K. VOHRA COMMITTEE REPORT EPUB DOWNLOAD. N N VOHRA COMMITTEE REPORT EPUB DOWNLOAD. NN Vohra Committee, set up to study the problem of criminalisation of politics, also took note of the.
Vohra Committee, which was constituted more than 24 years ago to unearth the criminalisation of politics and the nexus among criminals, bureaucrats and politicians. Vohra Committee are not available with it. Vohra Committee report that had become a part of the government record since 1 May Senior intelligence agency officials, who had followed Ibrahim, said that the findings of the N. The Committee, led by former Home Secretary N. However, it was not until August , when the Central government, facing the heat in the Naina Sahni murder case, agreed to table the report before Parliament.
Its relevance lies in the fact that ECG and electrogram patterns might be confusing, which should be taken into account during electrophysiological study EP in order to apply mapping and entrainment techniques at the right time. The pattern can be difficult to recognize if AV conduction is , but can be revealed by increasing the degree of block through massaging the carotid sinus or with intravenous verapamil, ATP or adenosine.
Figure 4. Variable atrioventricular conduction in a typical atrial flutter.
The atrial wave pattern stays regular, at a constant rate, although the morphology changes at some points due to the overlapping T wave. Reverse typical atrial flutter produces positive waves in lower leads, frequently with a sawtooth pattern, but what is most typical is a negative sawtooth wave, like a W, in V Figures 2 and 5. The typical atrial flutter circuit can produce an atypical ECG in patients with organic heart disease, surgical atriotomy, or atrial ablation lesions.
Figure 5. Three macroreentrant tachycardias MRT of the right atrium RA in a single patient, undergoing surgery for interatrial septal defect. Left: reverse typical atrial flutter.
The double negative waves "W" in V1 are typical, whereas in II, III and aVF the continuous wave has a positive sawtooth appearance, but also has prominent negative deflections. The electrocardiogram presents a pattern indistinguishable from typical atrial flutter.
RAO indicates right anterior oblique. Figure 6. Combined view of the relationships between the mechanisms of atrial macroreentry and the electrocardiogram ECG patterns.
The width of the triangle in each tachycardia mechanism indicates the relative frequency of this pattern with this mechanism. Ventricular Response to Flutter It is a classic paradox in atrial arrhythmias that a higher rate of atrial activation produces a greater degree of AV block and lower ventricular rate.
AV conduction is frequently during flutter, even while resting and under conduction-slowing agents; if the flutter rate is slower conduction can be up to Figure 7. However, ventricular rate can also be irregular due to complex block patterns in the AV node, which means that atrial fibrillation should not be systematically diagnosed when the ventricular response is irregular Figure 4. The irregularity of the QRS complexes can make recognition of a regular atrial pattern difficult, but this does not present an insurmountable difficulty provided there is attentive, careful observation.
Figure 7. Lower: some minutes later, there was a spontaneous change to conduction with normalization of the QRS complex. The clinical presentation of flutter is frequently associated with atrial fibrillation. In some cases, flutter initiates fibrillation and flutter ablation reduces the incidence of fibrillation.
When the patient has paroxysmal flutter and fibrillation, flutter tends to be more poorly tolerated due to the higher ventricular rate. When flutter is persistent, a high ventricular rate can cause dilated cardiomyopathy tachycardia-induced cardiomyopathy , that is reversible. In this situation there may be AV conduction with a wide QRS complex due to aberrant conduction, thus imitating a ventricular tachycardia13,14 Figure 7.
It has been estimated that the incidence of systemic embolism during flutter is around one-third that of fibrillation. When flutter is associated with fibrillation, risk is determined by the fibrillation. Studies comparing rhythm maintenance in relation to controlling the atrial fibrillation rate are not applicable to flutter, because there is poor clinical tolerance to the latter and due to the efficacy of ablation.
The availability of these 2 techniques makes it easy to resolve the problem of a very badly tolerated flutter with minimum risk. Figure 8. Cardioversion of an atrial flutter by rapid pacing in a patient carrying an atrial demand inhibited pacemaker AAI.
Rapid pacing spikes totally changes the pattern of typical atrial flutter on the ECG and, when interrupting pacing, the rhythm is paced on demand by the pacemaker itself. These primarily prolong the duration of the action potential without stopping myocardial conduction but, on the other hand, they incur the risk of causing polymorphic ventricular tachycardias torsade de pointes.
The incidence of recurrence of flutter after cardioversion could be lower than in fibrillation47,48 which means that, in the event that the arrhythmia is well-tolerated, a conservative strategy can be followed of clinical observation after the first episode has been cardioverted. The antiarrhythmic agent is maintained after ablation of the flutter circuit and is known as hybrid therapy.
The clear definition of the anatomical target enables a procedure guided by the use of a reference multipolar catheter covering the anterior and septal RA to record the activation sequence, and another steerable catheter for mapping, pacing and ablation of the CTI.
However, if there has been previous surgery, when several circuits are possible, or when ECG is untypical or presents several patterns, it is essential to confirm the involvement of the RA and CTI in the circuit by mapping and pacing techniques during spontaneous or induced flutter. Transient Entrainment of Flutter Transitory entrainment was described in patients with flutter in the period following open heart surgery,57 and later confirmed in other reentrant tachycardias.
Pacing the high RA at a frequency higher than that of flutter accelerated the atrial rate, but kept the waves negative in the lower leads; when interrupting pacing, the baseline pattern and rate were reestablished. If pacing changed the polarity of the wave, flutter was interrupted and gave way to sinus rhythm. This acceleration of the circuit via pacing, while maintaining its configuration, is the essence of entrainment.
In fact, it is the circuit that entrains activation, in the same way that rails keep a train on track, and this entrainment keeps the paced activation wave-front inside the circuit. Each pacing activates the circuit when penetrating it in the same direction as baseline activation and, at the same time, it pauses when penetrating it in the opposite direction Figure 9. Figure 9. Schematic representation of the entrainment mechanism of an MRT.
Circular reentrant activation developing into helical form spring or corkscrew is shown with a time dimension. Upper A : entrainment of typical atrial flutter by pacing S in the high RA. To the right, 2 spontaneous MRT cycles are shown, ascending in the septum and descending in the anterior RA.
Each pacing initiates an activation wave-front in the anterior RA, the same as flutter, but earlier, and at the same time initiates another wave-front toward the septal RA that collides with the ascending activation wave-front of the flutter circuit. The last paced wave-front reinitiates the flutter circuit at the rate prior to pacing and the first return cycle is equal to the flutter cycle, due to being paced in the same circuit. Lower B : when entrainment pacing is applied some distance from the circuit, the first unpaced cycle is equal to the baseline tachycardia within the circuit D , but the conduction times to and from the circuit are added to this interval at the pacing point, which produces a longer cycle F.
In A and B there is a "fusion" between the circuit activation wave-front that remains equal to baseline and the one changed by the paced wave-front. Entrainment has many interesting aspects but one is essential in practice: the duration of the return cycle the first unpaced one measured at the pacing point Figure 9. However, if the paced point is outside the circuit, the conduction times to and from the circuit are added to the return cycle of the tachycardia, which means that the return cycle at the pacing point is longer.
Based on this principle, entraining flutter from the CTI confirms or rules out whether it is typical flutter Figure Figure Hidden entrainment of typical atrial flutter pacing the cavotricuspid isthmus CTI. The upper panel schematically shows the activation sequence, descending in the anterior RA and ascending in the septal RA.
The first three cycles are entrained S , and from the CTI, and the cycle length LC of the entire circuit has been shortened to ms; however, the anterior RA is still activated from top to bottom and there is no change in the ECG hidden entrainment, without fusion. When interrupting pacing, flutter returns to the original wave-length ms and the return cycle in the CTI is equal to the flutter wave-length, which demonstrates that it is within the circuit.
Catheter Ablation The ablation target is the CTI, being the narrowest part of the circuit, well-delimited anatomically, easily accessible and distant from the AV node60 Figure Ablation attempts to produce a complete, bidirectional and persistent CTI block, which normally requires several radiofrequency or cryoablation applications, between the tricuspid edge of the isthmus and the IVC.
Some authors have suggested selecting the ablation points supported by entrainment,61,62 but this practice has been abandoned in favor of anatomical reference supported by the sequence of CTI electrograms.
If ablation is done during flutter, the activation is interrupted abruptly when the CTI is blocked, thus confirming its role in the circuit. However, block that interrupts flutter can be transitory and it is usually necessary to continue ablation, while RA and CTI activation is verified by pacing one side and the other of the latter. Interruption of a typical atrial flutter during the application of radiofrequency RF in the cavotricuspid isthmus CTI.
The ascending activation in the septal RA follows the descending one in the anterior RA until the CTI is blocked, which stops the activation wave-front. Once block is achieved it is necessary to verify its persistence over min, as it can still recur. Before cardioversion, either by direct current or pacing, the patient undergoes anticoagulation therapy for weeks or thrombi in the left atrium LA are ruled out via transesophageal echography.
Anticoagulation therapy is maintained for 4 weeks after cardioversion. In this sense, the interruption of persistent flutter by ablation is considered to be the same as cardioversion.
However, flutter ablation can still offer an interesting contribution to treatment in these cases, since flutter episodes tend to be more poorly tolerated and, when flutter occurs during pharmacologically treated fibrillation, flutter ablation enables controlling both arrhythmias in up to two-thirds of cases.
A detailed history can reveal the presence of chronic bronchopneumopathy, sleep apnea, hypertension, obesity or other processes whose treatment could help stop the underlying arrhythmogenic process. Although the ECG is frequently classifiable as "atrial tachycardia," it is common to use the term flutter to designate these atypical reentrant arrhythmias atypical flutter, left flutter Figure 6. Macroreentrant tachycardias due to atriotomy in the RA are well-known77 and, more recently, those caused by catheter ablation for atrial fibrillation.
They are not dependent on the CTI and have as a central obstacle an surgical atriotomy lesion or low voltage areas that are considered lesion-like, usually linked to normal anatomical obstacles. Lesion-Related Atypical Macroreentrant Tachycardia The simplest is based on a surgical lesion in the lateral RA, which forms a fixed obstacle on its own or is linked to the SVC by an area of functional block.
Entrainment from the CTI and septal RA shows return cycles longer than that of tachycardia Figure 12 , whereas the return cycles through lateral RA pacing are the same as those of the tachycardia.
Mapping the lateral wall shows a line of double potential electrograms from top to bottom, closed at its lower extreme by a fractionated electrogram, demonstrating slow conduction at the rotation point72,83,84 Figures 12 and The pressure of the mapping catheter at this point can stop the tachycardia, demonstrating its importance regarding the circuit; applying radiofrequency definitively interrupts the circuit.
Reentry circuits have occasionally been described around an interatrial septal defect closure patch. Activation of the anterior RA is descending. The return cycle is ms in the CTI and ms in the LS, longer than the baseline cycle length CL , because they lie outside the circuit. B: the MR circuit in right anterior oblique view. A line of double potentials is recorded in the center that converge in their lower part arrow , where the tachycardia was interrupted by applying radiofrequency.
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