Back to our patient from last week.
What happened next ?
|Click to enlarge|
- Sinus rate ~35
- Ventricular rate ~70
- Regularly irregular
- 1:1 Sinus complex : PVC
- LAD (<-30 deg)
- PR - Normal (~180-200ms)
- QRS - Prolonged (140ms)
- rsR' Pattern V1
- T Inversion aVR, V1, V2
- Broad Notched P wave Lead II
- PR - Normal (~200ms)
- QRS - Normal (100ms)
- QT - 400ms (QTc Bazette ~ 430 ms)
- Inferior (+90 deg)
- QRS - Prolonged (~140-160 ms)
- ST depression & T wave inversion II, III, aVF, V3,4,5
- Bifasicular block
- P Mitrale
- You can see notching in the ST segments of the PVCs in leads V1 & V2
- These are most likely retrograde p waves as highlighted by Christopher in his comments.
- They are not really visible in the inferior leads so we can't see whether they have the inverted morpholgy expected from retrograde conduction
- I'm unsure as to their origin or significance and I've asked our cardiology blog members to have a look and will update this post with their thoughts.
- There is a nice case with retrograde p waves here from The ECG Blog.
Our cardiology blog memebers have cast their expert eye over this week's ECG and given us their thoughts:
- The ectopic beats have a LBBB like morphology
- High to low activation in leads II,III and aVF
- Early transition from negative QRS complex to positive QRS complex in lead V2-V3
- The differential diagnosis indicates a left coronary cusp of the aortic valve source of ectopy and the anteroseptal right ventricular outflow tract source of ectopy.
- On the ST segment notching
- The differential is a p wave or artefact.
- If it was a retrograde p wave, the morphology would not be upright but rather inverted which makes this unlikely.
- If it is an antegrade p wave, then it is likely to be a non conducted p wave due to retrograde concealed conduction from the ventricular ectopic up to the AV node. I think this is the most likely diagnosis.
- Bala R, Marchlinski FE. Electrocardiographic recognition and ablation of outflow tract ventricular tachycardia. Heart Rhythm. 2007 Mar;4(3):366-70. Epub 2006 Nov 17. PMID: 17341405 Full text here.
- Haqqani HM, Morton JB, Kalman JM. Using the 12-lead ECG to localize the origin of atrial and ventricular tachycardias: part 2--ventricular tachycardia.J Cardiovasc Electrophysiol. 2009 Jul;20(7):825-32. PMID: 19302478
Life in the Fast Lane
- PVCs here
- Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.