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- 72 bpm
- Regular
- A-V Sequential Pacing
- Nil native cardiac activity
- Extreme Axis Deviation
- QRS - Prolonged (200-220 ms)
- Appropriate discordance ST segments / T waves
- Lead V3 not quite isoelectric but there appears to be some concordant ST depression
- This was non-dynamic with no history of chest pain
- Need correlation with old and serial ECG's
- Sgarbossa criteria do not apply to LV / CRT pacing only RV pacing with LBBB morphology
Additional:
- Ventricular pacing consists of 2 spikes ~40ms apart
- Likely LV pacing followed by RV pacing
- Referred to as LV-RV Offset
- Negative QRS vector leads I, II, III, aVF, V4-6
- Due to infero-apical lead positioning
- Wide tall R wave lead V1 & V2
- Predominant LV capture
- Notching within QRS complex
- Likely reflects significant myocardial scarring and injury as does QRS prolongation
- Bi-Ventricular Pacemaker / Cardiac Resynchronization Therapy (CRT)
What happened ?
The patient had worsening uraemia likely secondary to increasing diuretic dosing contributing to his anorexia with general de-conditioning due to chronic illness. He was admitted for medication review with the aim of symptomatic improvement.
More examples
We've had a couple of other ECG cases with CRT pacing that can be found here:
- ECG of the Week - 9th September 2014
- A very special ECG and our most viewed ECG case ever !
- ECG of the Week - 2nd June 2014
- A very similar ECG to the one we see here.
Further Reading
For more on Cardiac Resynchronization Therapy (CRT) check out the following resources:
- European Society of Cardiology 2013 Guidelines on Cardiac Resynchronization Therapy
- Medtronic Connect Portal - Manufacturers Information (Requires free sign-up)
- AHA Patient's Guide on CRT
Life in the Fast Lane
Textbook
- Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.
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