51/F, Paroxysmal AF for 3 years
Preop. Consultation for bradycardia
Medication: flecainide 100mg/d, bisoprolol 2.5mg/d
CASE 1 KHRS ARC 2012-BASIC
HR: 55bpm, no subjective Sx.
What is your diagnosis?
1. Sinus bradycardia
2. Sinus bradycardia with sinus arrhythmia
3. Ventricular premature complex
4. Atrial premature complex
CASE 1 KHRS ARC 2012-BASIC
CASE 1 KHRS ARC 2012-BASIC
SA
N A
AVN
V
RP:
180ms
RP:
200ms
RP:
200ms
RP:
160ms
SCL:
1100ms
SCL:
1100ms
PP:
1640ms
PP:
1680ms
PP:
1680ms
PP:
1640ms
PR:
360ms
PR:
420ms
LBBB
CASE 1 KHRS ARC 2012-BASIC
ECG abnormality on this strip:
1. Non-conducted APC
2. Conducted APC with prolonged PR interval
followed by aberrant conduction
3. Conducted APC with prolonged PR interval
42/M, 선교사 (필리핀 거주)
Consultation for ECG abnl on health examination
Echo: unremarkable
CASE 2 KHRS ARC 2012-BASIC
No subjective Sx.
CASE 2 KHRS ARC 2012-BASIC
What is your diagnosis?
1. Atrial premature beat
2. Junctional premature beat
3. Ventricular premature beat
4. Non of above
CASE 2 KHRS ARC 2012-BASIC
SA
N A
AVN
V
SCL:
740ms
SCL:
720ms
SCL:
1420ms
RP: 60ms
Junctional premature beat
CASE 3 KHRS ARC 2012-BASIC
69/M, no prior medical records
c/c: palpitation for 1 month
Echo: unremarkable, Holter PVC 2400/day
CASE 3 KHRS ARC 2012-BASIC
SAN
A
AVN
V
SCL:
960ms
SCL:
960ms
SCL:
960ms
PP:
1920ms
PP:
1920ms
PVC with full compensatory pause
SCL:
960ms
SCL:
960ms
SCL:
960ms
SCL:
960ms
CASE 4 KHRS ARC 2012-BASIC
67/M, HBP 5 years ago
c/c: palpitation for 2 weeks Initial ECG
CASE 4 KHRS ARC 2012-BASIC
SAN
A
AVN
V
RR:
1100ms
SCL:
1040ms
SCL:
1040ms
SCL:
1040ms
SCL:
1040ms
SCL:
1040ms
SCL:
1040ms
RR:
1100ms
RR:
1100ms
RR:
980ms
RR:
980ms
RR:
980ms
PR:
180ms
PR:
240ms
Interpolated PVC with retrograde concealed conduction
CASE 5 KHRS ARC 2012-BASIC
37/M, Paroxysmal AF (lone AF), 1st detected
c/c: intermittent palpitation
AF with intermittent wide QRS complex with RBBB like pattern
CASE 5 KHRS ARC 2012-BASIC
RR:
1060ms
RR:
760ms
RR:
720ms
RR:
440ms
RR:
440ms
RR:
420ms
RR:
400ms
Short-long-short sequence followed by
different degrees of RBBB
Phase 3 aberration occurs following a long-short cycle
sequence because the refractory period of the beat
following the long cycle is prolonged
Sudden marked shortening of the ventricular cycle
length (phase 3 aberration)
65/M, Flank pain
CASE 6 KHRS ARC 2012-BASIC
* **
Atrial couplet
- Blue: sinus P
- *Blue: premature P with normal conduction
- **Blue: premature P with non-conduction
CASE 6 KHRS ARC 2012-BASIC
12/F, Nausea
CASE 7 KHRS ARC 2012-BASIC
* * * * *
Atrial trigeminy with dual AV nodal pathway
- Blue: sinus P with fast pathway conduction
- Red: premature P with slow pathway conduction
- *Blue: sinus P with non-conduction
CASE 7 KHRS ARC 2012-BASIC
* * * * * * * *
Sinus rhythm with dual AV nodal pathway and ventricular triplets
- Blue: sinus P with fast pathway conduction
- *Blue: sinus P with slow pathway conduction
- Ventricular triplets: may be due to pacemaker leads because the QRS
morphology was similar with pacing QRS morphology.
During pacing Yellow: lead of PM
CASE 7 KHRS ARC 2012-BASIC
69/M, Syncope
CASE 8 KHRS ARC 2012-BASIC
Ventricular tachycardia
- *: capture beat
- **: fusion beat
CASE 8 KHRS ARC 2012-BASIC
** *
58/M, Abnormal ECG
CASE 9 KHRS ARC 2012-BASIC
Wandering pacemaker
CASE 9 KHRS ARC 2012-BASIC
69/F, Dizziness
CASE 10 KHRS ARC 2012-BASIC
Junctional escape beats
- Blue: retrograde P
CASE 10 KHRS ARC 2012-BASIC
75/M, Dyspnea on exertion
CASE 11 KHRS ARC 2012-BASIC
Atrial fibrillation
Complete AV block with junctional escape beats
CASE 11 KHRS ARC 2012-BASIC
83/F, Dizziness
CASE 12 KHRS ARC 2012-BASIC
Sinus arrest/pause with ventricular escape beats
- Blue: sinus P
CASE 12 KHRS ARC 2012-BASIC
30/F, SVT 로 Cath. Room에서 sedation 후 ECG
CASE 13 KHRS ARC 2012-BASIC
After Atropine 1 mg IV
CASE 13 KHRS ARC 2012-BASIC
Intracardiac Electrogram
CASE 13 KHRS ARC 2012-BASIC
Intracardiac Electrogram after Atropine
CASE 13 KHRS ARC 2012-BASIC
CASE 14 KHRS ARC 2012-BASIC
31/F, Intermittent palpitation with dizziness
CASE 14 KHRS ARC 2012-BASIC
During palpitation
After atropine
CASE 14 KHRS ARC 2012-BASIC
After atropine
CASE 14 KHRS ARC 2012-BASIC
CASE 15 KHRS ARC 2012-BASIC
56/M, Sudden onset anterior chest pain for 1 hr
CASE 15 KHRS ARC 2012-BASIC
30 min after thrombolytic Tx
CASE 15 KHRS ARC 2012-BASIC
60 min after thrombolytic Tx
CASE 15 KHRS ARC 2012-BASIC
Percutaneous Coronary Intervention
CASE 16 KHRS ARC 2012-BASIC
50/M, Palpitation
PR interval 220 ms
PR interval 160 ms
CASE 16 KHRS ARC 2012-BASIC
AV nodal reentry
CASE 17 KHRS ARC 2012-BASIC
24/F, Palpitation
CASE 17 KHRS ARC 2012-BASIC
Termination by Adenosine
CASE 17 KHRS ARC 2012-BASIC
F/U ECG after Termination
Def. : beat to beat variation in R wave amplitude > 1mm
Favor orthodromic AVRT
Rate-related phenomenon
However, not specific for tachycardia mechanism
CASE 17 KHRS ARC 2012-BASIC
QRS alternans during narrow QRS tachycardia
CASE 17 KHRS ARC 2012-BASIC
Atrioventricular reentrant tachycardia
89 F, Hypertension Chest pain
KHRS ARC 2012-BASIC
2011-06-18
CASE 18
PCI
2011-06-18
KHRS ARC 2012-BASIC CASE 18
ECG after PCI
2011-06-18
KHRS ARC 2012-BASIC CASE 18
F/U ECG
KHRS ARC 2012-BASIC CASE 18
2011-06-18
2011-06-19
2011-06-19
2011-06-20
83 M, DM Hypertension, Syncope
KHRS ARC 2012-BASIC
2008-11-26
CASE 19
ECG
2008-11-26
KHRS ARC 2012-BASIC CASE 19
ECG
2008-11-28
KHRS ARC 2012-BASIC CASE 19
ECG
2008-12-01
KHRS ARC 2012-BASIC CASE 19
61/M, Feb 10’ AAA rupture (emergency OP) ICU care Recurrent pause during suction/position change
2010-03-21
KHRS ARC 2012-BASIC CASE 20
Rhythm strip during pause
2010-03-21
KHRS ARC 2012-BASIC CASE 20
A
AVN
V
PR : 200ms
PP : 660ms 780 800 1040 920 880 800
810 2580 1800 1040 1460
240 160 160 200
740 880 880 880 720
210 240 320 200
RR : 660ms 720 800
Vagal AV block
• Slinical history highly suggestive of heightened vagal tone (i.e., during
micturition, phlebotomy, etc.),
• Significant PR prolongation or Wenckebach before initiation of AVB
• Prolonging P-P interval during ventricular asystole
• Resumption of AV conduction on sinus acceleration (shortening of P-P
interval)
• No retrograde activation of the His bundle with a ventricular or His
extrasystole to reset and abolish AVB
Heart Rhythm 2009;6:1229 –1234
83/F, AGC ’11 Recurrent syncope
2011-11-15
KHRS ARC 2012-BASIC CASE 21
ECG
2011-11-15
KHRS ARC 2012-BASIC CASE 21
ECG
2011-11-16
KHRS ARC 2012-BASIC CASE 21
Previous ECG
2011-06-11
KHRS ARC 2012-BASIC CASE 21
Trifascicular block
RBBB + alternating LAFB/LPFB Bifascicular block + I AV block LBBB + I AV block Alternaging RBBB/LBBB esp with I AV block
86/F, PTGBD 06.01 Dyspnea
2011-06-09
KHRS ARC 2012-BASIC CASE 22
QTc 642ms K 3.3mmol/L Ca 8.6mg/dL (8.6-10.0) Mg 1.2mg/dL (1.6-3.0)
ECG
2011-06-13
K 3.2 mmol/L
K 3.8 mmol/L
K 4.1 mmol/L
K 4.3 mmol/L
KHRS ARC 2012-BASIC CASE 22
75 M, DM Hypertension, Syncope
KHRS ARC 2012-BASIC CASE 23
2012-04-30
ECG at admission
2012-04-30 K 8.2mmol/L, BUN/Cr 27/1.47mg/dL
KHRS ARC 2012-BASIC CASE 23
FU ECG
2012-04-30 K 4.2mmol/L
KHRS ARC 2012-BASIC CASE 23