Graded Phenomenon (Yasser’s Phenomenon) based on catching the graded changes in ECG tracings in understanding the mechanisms of arrhythmias.

1. Heart and Cardiovascular
Congress 2021

2. Dr. Yasser Mohammed
Hassanain Elsayed
MB Bch, PGDip Cardiology
(Middlesex University, RILA)
Researcher and author
Critical Care Unit
Work: Egyptian Ministry of Health
(MOH)

4. Graded
Phenomenon
(Yasser's Phenomenon)

5. Learning objectives
• Discovery and historical bit
• Know the definition
• Understanding the hints on varieties
• Understanding of GP
• The risk
• How to deal with it? (Management)
• Conclusion and Recommendations

6. Table 1- showing remarks of the study
method and data.
Issue Definition
Title Graded phenomenon (Yasser's phenomenon); A novel
Electrocardiographic phenomenon change the arrhythmia
directory
Estimated Enrollment 30 participants
Study Type Observational
Observational Model Case-only
Time Retrospective
Study Start Date January 13, 2016
Estimated Study Completion Date February 9, 2020
Analytic method Comparative using percentage %

7. Discovery

8. 1. History
Either
• Over about 5 years of subsequent
immediate serial ECG tracings.
or
• Subsequent changes, but in the
same ECG tracing.

9. 2. principle of the “Graded
phenomenon”
• It is based on catching the
graded changes in the serial ECG
tracings.
• Or even the same ECG tracing
regarding the arrhythmias.

10. Definition

11. Let the definition for a moment.

12. Varieties

13. 1. “GP” Variant I Classification:
According to the extension direction for arrhythmia:
1. The up-grading phenomenon with the right to the left
extension.
2. The up-grading phenomenon with the left to the right
extension.
3. Up-grading bidirectional sectors of tachycardia (BSOT).
4. Intermittent Wandering pacing rhythm with the left to the
right extension.

14. 2. “GP” Variant II Classification:
According to the grading and conversion of arrhythmia of
GP:
1. Up-grading.
2. Down-grading.
3. Fixed–change.
4. Spontaneously changed to normal sinus rhythm.
5. Spontaneously changed to another arrhythmia.
6. Therapeutic reversal.

15. 3. “GP” Variant III Classification:
According to the risk of arrhythmia of GP:
1. High risk.
2. Non-risk.
3. Still-risk.

16. After these variant
classifications; let me to
introducing examples for
understanding

17. 1. Upgrading “GP” with right
to left extension

18. A 60-year-old married, housewife, Egyptian
female, presented to the Emergency Room
(ER) with orthopnea of progressive course.
The patient was admitted and managed in
the intensive care unite (ICU) as chronic
heart failure (CHF) with hypertensive crises
(HC). She gave a history of diabetes and
calcular cholecystitis.

19. “Upgrading GP with the right to left extension”; started in V1-6 leads (A-tracing), II, III, and aVF with V1-6 Leads (B-tracing), to all
ECG leads (C-tracing) Randomly mixture of bigeminy PVCs and trigeminy PVCs. (D-tracing) Runs of VT (3 Subsequent PVCs) (E-
tracing) disappearance of the previous changes after NTG with evidence of old silent inferior-anterior MI (F-tracing).

20. 2. Progressive polymorphic
VT (Tdp); upgrading GP with
left to right extension

21. A 58-year-old married Egyptian housewife
female patient presented to the POC with
dizziness, dyspnea, and palpitations. The
patient gave a history of psycho-familial
troubles. Clinically, she had appeared
myxedematos. There was sub-clinical
hypothyroidism and congestive heart failure
(CHF).

22. “Upgrading GP with the right to left extension”; started in V1-6 leads (A-tracing), II, III, and aVF with V1-6 Leads (B-tracing),
to all ECG leads (C-tracing) Randomly mixture of bigeminy PVCs and trigeminy PVCs. (D-tracing) Runs of VT (3 Subsequent
PVCs) (E-tracing) disappearance of the previous changes after NTG with evidence of old silent inferior-anterior MI (F-tracing).

23. 3. Progressive bidirectional
sectors of tachycardia (BSOT)
“GP”

24. A 75-year-old married Egyptian housewife
female patient presented to the POC with
chest pain, dyspnea, and palpitations. The
patient was initially diagnosed as
hypertensive crises with junctional
tachycardia.

25. GP + an interesting progressive bidirectional sectors of tachycardia (BSOT) started with NSR in between until becoming total tachycardia in all
ECG tracing. BSOT initially started in the first part of I, II, and III, aVR, aVL, and aVF leads (A tracing; blue color) extended to the last part of I, II,
III, and aVR, aVL, and aVF and the first part of, aVR, aVL, aVF, and V1-3 leads (B tracing; green color) the first part of I, II, III, the middle part of
aVR, aVL, aVF and V1-3, and last part of I, II, III, and V4-6 leads (C tracing; gold color) extend to last part of aVR, aVL, and aVF, and all V1-6 leads
(D tracing; green color) lastly it includes all ECG leads (E tracing; turquoise color).

26. 4. Intermittent Wandering
pacing rhythm (WPR) with a
progressive left to the right
extension

27. An 11-year-old Egyptian boy student patient
presented to the POC with pleuritic chest pain.
There was no history of heart disease.

28. Intermittent Wandering pacing rhythm with a progressive left to the right extension.
It progresses from partial junctional rhythm becoming total junctional rhythm in all ECG tracing except lead I and aVL spontaneously
normalized. WPR initially started in I, II, and the first part of III, aVR, aVL, and aVF leads (green arrows and color) sinus bradycardia in
the remaining part of aVR, aVL, and aVF leads (black and blue arrows, and color) junctional rhythm in part of V1-3 (green arrows and
color) sinus bradycardia in the remaining part of V-3, and all V4-6 leads (black and blue arrows, and color) (A. ECG tracing) JR
including all ECG tracing except lead I and aVL (B. ECG tracing) spontaneously normalized (C. ECG tracing)

29. 5. Progressive accelerated
junctional rhythm (AJR) with
the right to the left extension

30. A 37-year-old married Egyptian housewife
female patient presented to the POC with
irritable bowel syndrome with chest tightness,
and palpitations. She gave a history of anxiety
due to delayed infertility. The patient initially
diagnosed as anxiety with a junctional rhythm.

31. Junctional rhythm (JR) with progressive right to left extension with a NSR in between until becoming total JR in all ECG
tracings
JR initially started in V1-6 leads (green arrows and color) + the remaining are NSR (blue arrows and color) (A. ECG tracing),
extended to all ECG leads except AVL(brown arrows and color) (B. ECG tracing) spontaneously normalized in all ECG leads
(C. ECG tracing;).

32. 6. Fixed trigeminal PVCs

33. A 50-year-old married Egyptian male teacher
patient presented to the POC with dizziness
and palpitations. The patient appeared
anxious. There was a recent history of
psychological stress. There was a history of old
MI.

34. Fixed trigeminal PVCs in anxiety and old IMI
A-C tracings showing fixed trigeminy PVCs.

35. 7. Up-grading PVCs in
suspected of acute
pulmonary embolism
( thrombophilia)

36. An 88-year-old married, worker, Egyptian male
patient presented in the ER with tachypnea
and palpitations. The patient gave a recent
history of bilateral LL swelling. The patient has
a history of hypertension, AF, recurrent
cerebrovascular strokes with bulbar palsy. At
home, the patient missed his warfarin (3 mg).
He was admitted to the ICU as suspected of
acute pulmonary embolism.

37. Up-grading PVCs in suspected pulmonary embolism ( thrombophilia)
AF, sinus arrest (A. tracing) polymorphic VT (B. tracing) multifocal PVCs(C+D tracings) runs of VT(E+F tracings).

38. 8. Fixed graded PVCs in CHF;
Hexagimeny-trigimeny-
trigimeny hexagimeny

39. An 87-year-old married Egyptian male
farmer presented to the POC with
palpitations. There was a history of
compensated CHF and cirrhotic liver
disease.

40. (6-3-3-6) in a serial fixed manner

41. 9. Fixed grading in PVCs;
starting as; Quadrigimeny-
bigimeny-bigimeny
quadrigimeny

42. A 75-year-old married Egyptian female
housewife presented to the POC with
dizziness. There was a history of
compensated chronic heart failure (CHF)
and obstructive sleep apnea (OSA).

43. (4-2-2-4) in a serial fixed manner.

44. 10. Non-fixed PVCs variation in
grading (in angina post-
tramadol)

45. A 70-year-old married Egyptian male carpenter
presented to ER with chest pain, dyspnea, and
dizziness. He gave a recent history of ingested
3 tablets of oral tramadol (100 mg). There was
a history of urinary bladder carcinoma.
(Toxicity case).

46. Non-fixed variation grading PVCs.

47. 11. Up-grading PVCs (in CHF)

48. A 66-year-old married Egyptian male
carpenter presented to the ED with
orthopnea. The patient had a recent history
of CHF. He was admitted to the ICU as a
CHF with AMI.

49. Up-grading PVCs from less frequent (trigeminy)

50. 12. Insignificant isolated PVCs

51. A 43-year-old married Egyptian female
housewife presented to the POC with
palpitations. There was a history of psycho-
familial troubles.

52. Insignificant isolated PVCs

53. 13. Insignificant isolated PVCs
but important

54. A 60-year-old married Egyptian female
housewife presented to the ER with dizziness.
There was a history of compensated chronic
renal failure (CRF) on regular hemodialysis.
She was admitted to ICU with symptomatic
bradycardia.

55. An insignificant isolated PVCs but important (Sinus bradycardia with
few PVCs)

56. 14. Down-grading with less
frequency of PVCs (in CHF)

57. A 66-year-old married Egyptian male
electrician presented to the ER with
orthopnea. The patient had a recent history of
CHF. He was admitted to the ICU as a CHF.

58. Down-grading less frequent PVCs

59. 15. Sinus arrhythmia spontaneously graded to
normal
(Passing phenomenon or Yasser’s phenomenon)

60. A57-year-old married housewife Egyptian
female patient presented to the ER for
inguinal hernia preoperative preparation.

61. Sinus arrhythmia spontaneously graded to normal

62. 16. PSVT spontaneously
graded to AF

63. A 43-year-old married Egyptian male worker
presented to the ER with palpitations and
headaches. He was a heavy cigarette smoker.
He was admitted to the ICU as PSVT with
HCC.

64. PSVT spontaneously graded to AF

65. 17. JT spontaneously graded
to sinus tachycardia

66. A 44-year-old married, driver, heavy
cigarette smoker, Egyptian male patient
presented in the ER with acute severe chest
pain and palpitations. The chest pain was
anginal The patient gave a recent history of
using substance abuse. He was admitted to
the ICU and managed in the ICU as unstable
angina.

67. JT spontaneously graded to sinus tachycardia

68. Mechanisms of cardiac arrhythmias

69. Table-2 Summery mechanisms of cardiac
arrhythmias.
No.
Disorders in impulse figuration Disorders in impulse conduction
1.
2.
A. Automaticity
1. Altered normal automaticity
2. Abnormal automaticity
B. Triggered activity
1. Delayed after-depolarization
2. Early after-depolarization
(EADs)
A. Reentry
1. Anatomic reentry
2. Functional reentry
Modified from Gaztan L et al (2012)

70. The Risk

71. Table-3 Risk markers and red flags for PVC’s with a higher risk for SCD
Modified from Elsayed et al (2019)

72. • The risk in “Graded phenomenon” is classified into:
• High risk; 40% (12 cases)
• Non-risk; 43.33% (13 cases)
• Still-risk; 16.67% (5 cases)

73. Figure 1 - showing the graphical presentation for risk outcomes in “GP”.

74. Table 4- showing types of grading phenomenon, changes, course, and the risk.

76. AJR; accelerated junctional rhythm, BSOT; bidirectional sectors of tachycardia, CHF; congestive heart failure, JT; junctional
tachycardia, NSR; normal sinus rhythm, PVCs: premature ventricular contractions, PVT; polymorphic ventricular
tachycardia, SCD; Sudden cardiac deaths, TdP: Torsades de pointes, VT ventricular tachycardia

77. The changes in “GP” is classified into:
• Up-grading; 20% (6 cases)
• Down-graded; 10% (3 cases)
• Changed to NSR; 43.33% (13 cases)
• Changed to AF; 3.33% (1 case)
• Changed to sinus tachycardia; 3.33% (1 case)
• Therapeutic reversal; 3.33% (1 case)
• Fixed –change; 10% (3 cases)
• Variable change; 6.67% (2 cases)

78. Figure 2 -showing the graphical presentation for developmental changes in the “GP”

79. • The course in “Graded phenomenon” is classified into:
• Progressive; 43.33% (13 cases)
• Regressive; 10% (3 cases)
• Intermittent; 6.67% (2 cases)
• Constant; 16.67% (5 cases)
• Transient; 20% (6 cases)
• Non-fixed variation; 3.33% (1 cases)

80. Figure 3-showing the graphical presentation for risk outcomes in “GP”.

81. Definitions

82. Definitions in the changes of “GP”

83. • Up-grading: It is meaning that the change either from low serious arrhythmia
to higher serious arrhythmia, or more extension for the current serious
arrhythmia, or ending to serious arrhythmia or just extension for a benign
arrhythmia e.g. case No. 1. Up-grading may be included an up-grading type of
arrhythmia as in case No. 7.
• Down-grading: It is meaning that the change either from higher serious
arrhythmia to low serious arrhythmia, or less extension for the current serious
arrhythmia, or ending to the benign or non-serious arrhythmia e.g. case No. 15.
• Fixed–change: It is meaning that the current arrhythmia is constant in the
serial ECG or even the single ECG tracing e.g. case No. 6.
• Spontaneously changed to normal sinus rhythm: It is meaning that the
current arrhythmia is spontaneously changed to normal sinus rhythm with no
uses of medications or therapeutic maneuvers like DCC and Valsalva’s e.g. case
No. 16 and17.

84. • Spontaneously changed to another arrhythmia e.g. sinus tachycardia e.g.
case No. 19.
and atrial fibrillation e.g. case No. 18.
• Therapeutic reversal: It is meaning that there is a new arrhythmic change
after using the traditional antiarrhythmic e.g. case No. 14.

85. Definitions in the extension of arrhythmia in “GP”

86. • The up-grading phenomenon with the right to left extension: It
is meaning that the arrhythmic change starting from the right side
of ECG tracing directed toward its left side e.g. case No. 1.
• The up-grading phenomenon with the left to right extension: It
is meaning that the arrhythmic change starting from the left side
of ECG tracing directed toward its right side e.g. case No. 2.
• Up-grading bidirectional sectors of tachycardia (BSOT): It is
meaning that the arrhythmic change starting as sectors of
tachycardia then gradually extend to both left and right side of
ECG tracing until becoming complete tachycardia e.g. case No. 3.
• Intermittent Wandering pacing rhythm with the left to right
extension: It is meaning that the change occurring intermittent
manner then extends from left to right e.g. case No. 4.

87. Definitions in the risk in arrhythmia with “GP”

88. • High: This is meaning that there will be possible serious outcomes like;
sudden cardiac deaths congestive heart failure, Torsades de pointes, and VT
ventricular tachycardia e.g. case No. 1, 2, and 7.
• Non-risk: This is meaning that there will no be possible serious outcomes e.g.
case No. 4, 5, and 14.
• Still-risk: This is meaning that there are no current possible serious outcomes
but maybe with passing the time e.g. case No. 18, 24, and 26.

89. Management of GP

90. • Essential points are considered in the management of GP
• Serial ECG tracings
• The risk
• The course
• The clinical status
• GP can be treated as a case by case according to the above considerations.
• Multidisciplinary subspecialty teams are advised for further understanding of GP
• The recommended multidisciplinary subspecialty teams will be including;
• Cell biologist
• Electro-physiologist
• Cardiologist
• Pathophysiologist.

91. Conclusion and Recommendations

92. • Graded phenomenon (Yasser's phenomenon) is a novel
electrocardiographic phenomenon change the arrhythmia directory.
• It is a crucial step for understanding arrhythmia.
• The phenomenon is a new strong guide for monitoring and follows up
arrhythmic patients in cardiovascular patients.
• There are interlacing correlations between the “passing phenomenon”
and the current “Graded phenomenon” especially in cases of arrhythmia that
is spontaneously changed to normal sinus rhythm with no uses of medications
or therapeutic maneuvers like DCC and Valsalva’s e.g. case No. 16 and 17.
• Electrophysiology studies (EPS) is recommended for more future study and
understanding the “Graded phenomenon”
• Physiological study for the cellular biology may be advised future options
for the “Graded phenomenon”.

93. References

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2019).
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Yasser’s Phenomenon) Conveys the Traditional Cardiovascular Management;
Interpretations and Reassurance; Retrospective Observational Study. Anaest & Sur
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95. Thank you