Here's great case submitted by Dr John M
A 58 year old women presents with episodes of "greying out" with exertion. She has had a slightly higher than usual heart rate for a few days, but of late, any exertion brings on near syncopal episodes.
Past history includes long-standing atrial fibrillation. In the past two years, she has had two left atrial ablations. The first ablation included pulmonary vein isolation alone, but the second one, done 3 months prior included repeat pulmonary vein isolation, plus left a left atrial roof line, mitral isthmus line and multiple ablations of complex-fractionated electrograms.
Exam: She is an obese female, with a BMI of 38, BP 98/58, HR- 170, RR-24.
She appears anxious and slightly diaphoretic.
Neck veins not distended
Lungs are clear
Heart exam reveals tachycardia
No peripheral edema
The first ECG is here...
The nurse calls to tell me she has converted to Sinus Rhythm. After looking at this second ECG, do you concur?
After a brief procedure later in the day, this ECG is recorded.
Long QT, creating pseudo P-waves in second ECG. What was her potassium? Did you administer a dysrhythmic?
ReplyDeleteFirst 12L - Atrial fibrillation with RVR. Second 12 L Atrial flutter
ReplyDeleteleft atrial tachycardia (positive P wave in V1)in both ECGs with different AV conduction modes
ReplyDeletein second ECG, the p waves are hidden within the QRS complex
resting ECG in sinus rhythm is showing notched p waves and 1st degree AV block
PR prolonged and not regular- complete heart block?
ReplyDeleteRS wave in V1, V2, V3 with monophasic wave in V6 and I lead-LBBB
i think we can't add anything into diagnosis when there is LBBB
first is atrial fibrillation, second atrial flutter or some other macro reentry, probably from left atrium, third is sinus rythm:)
ReplyDeletemaybe they need to check the lines in the left atrium.
atrial flutter with variable block in first ECG;second ECG is flutter with 3-1 block, finally reverted to Sinus rhythm in 3rd
ReplyDelete1ST ecg - irregularly irregular atrial fibrilation, multifocal atrial firing indicated by the hidden 'p'after the QRS complexes and those falling on the 'T'waves...patient is compromised at a rate of 170bpm loosing the 30% atrial kick... 2nd ecg - regular but abnormal atrial activity continues...leading to a complete heart block in the 3rd ECG...
ReplyDeletecomplete heartblock in 3rd ECG???? Are you serious??
ReplyDeleteI see a perfect sinusrythm:)
I think first is AFib with a rapid response. The second looks regular, but still looks like it has the hidden P's just after the QRS (junctional?). Sinus brady in the third. Is there a good way to calculate the QT in an irregular rhythm?
ReplyDeleteHey all, thanks for the comments
ReplyDeleteIn the first record, the first four QRS complexes are regular at a rate of about 340 sec (or so). In lead 2, after the fourth QRS, there are discernible slow flutter waves (or call them fast atrial tach complexes). But clearly there is organized atrial activity.
The second ECG is after the patient is put at rest in a gurney and given IV beta blocker. The QRS complexes are now completely regular. Interestingly, the QRS rate on the second ECG is 1/2 the rate of the first 4 complexes on the first ECG.
Therefore, the second ECG shows the same slow atrial flutter (or fast atrial tachycardia) as the first record, only now there is fixed 2:1 conduction, whereas on the first ECG, the avnode conduction was faster--even as fast as 1:1 conduction.
The third ECG is after cardioversion.
Adam, I believe the QT on the first two records appears long because the aflutter wave merges with the t-wave, but this patient is on the known QT-prolonging drug, dofetilide and the QT is "generous."
Take home messages:
1.Slow atrial flutters are very common after numerous RF lesions are placed in the left atrium. These burns, if not continuous, or if reconnection occurs can create a favorable milieu for reentry arrhythmias.
2. Paradoxically, "slower" atrial arrhythmias, like atrial flutter, often prove more difficult to control the ventricular response. They bombard the AV node more regularly and more slowly, thereby creating less concealed conduction into the AV node. As such, organized atrial tachycardia or slower atrial flutters, are more likely to be associated with1:1 AV node conduction. Example: Flecanide can slow a 300 bpm aflutter to a 240 bpm flutter. With exertion, a patient may conduct 1:1 to 240 bpm, but not to 300 never seen an adult av node conduct that fast). 1:1 flutters are the most common proarrhythmia with the Type 1C drugs.
Look for more atypical flutters, as post-AF ablation patients become greater in number.
JohnM