Case reports from Michael Rosengarten

This case report is kindly provided by Michael Rosengarten from McGill and is part of the McGill Cases. These cases come from the McGill EKG World Encyclopedia. Previous Case: / | Next Case: McGill Case 1

Conduction Abnormalities

Intraventricular conduction defect

• A 70 year old woman with recurrent ventricular tachycardia and a severe intra-ventricular conduction defect.
• A 62 year old man with a severe intra-ventricular conduction defect simulating ventricular bigemini.

Right Bundle Branch Block

• An elderly man with RBBB and possible LPHB.
• An elderly man with RBBB and atrial flutter.
• A patient with PACs conducted with a RBBB.
• A patient with a RBBB and PACs.
• A patient with a RBBB secondary to massive Pulmonary embolism.
• A 35 yr. old patient with possible Chagas disease induced right bundle branch block.

Left Bundle Branch Block

• Recordings of rate dependent left bundle branch block.
• Case two.
• Left bundle branch block and first degree A/V block.

Left Anterior Fasicular Block

• Case one (in the setting of an acute anterior wall MI)
• in a middle aged man with first degree block.
• an 80 year old man.
• A 77 year old man with previous myocardial infarction.

Left Posterior Fasicular Block

• A 19 year old boy with an normal echocardiogram.

Bifasicular block

Right bundle branch block with left anterior hemi-block

• In a 41 year old patient who had had surgical correction of Tetalogy of Fallot.
• With possible RVH.
• In a patient with atrial fibrillation.
• In a elderly man with possible left atrial abnormality.
• 54 year old man with a heart transplant.

Right bundle branch block with left posterior hemi-block

• A patient on the hospital ward with RBBB, Left Posterior Hemiblock, criteria for LAA and RAA.
• An elderly woman with a history of ventricular tachycardia

Alternating Bundle Branch Block

• Case one

Trifasicular block

• Case one
• Case two
• Case three

First degree block:

• A 77 year old man with previous myocardial infarction.
• A 63 year old man
• second case
• third case
• In a middle aged man with LAFB
• In a 20 year old woman with Ebstien's anomaly
• In an 87 year old man with a VVI pacemaker

Second degree block

Mobitz I

• Mobitz I A/V block and high grade A/V block from a woman with pre-syncope.

Mobitz II

• A patient with MobitzII A/V block post pacemaker implant for syncope
• From a Holter recording from a middle aged woman, also shows 2:1 block

Complete heart block

• Complete heart block detected with a Reveal implantable monitor.
• A 65 year old woman with tiredness and difficulty walking. The EKG shows complete heart block.
• An 85 year old patient with previous trifasicular block

Sinus Node Block:

• A middle aged woman treated for atrial fibrillation with a possible sinus node exit block (Mobitz 1)

Arrhythmias

Supraventricular Arrhythmias

Sinus pauses

• From a Holter monitor
• On termination of atrial fibrillation

Premature atrial complexes

• Case one
• Case two
• PACs in trigemini

Atrial fibrillation

• Atrial fibrillation in a patient with a RBBB and LAHB
• Atrial fibrillation in an elderly man
• A 64 year old woman with atrial fibrillation and left ventricular hypertrophy
• A 84 year old woman
• Case three with a first EKG showing left atrial abnormality and a second with atrial fibrillation

Supraventricular Tachycardia

Without block

• A 70 year old man with supraventricular tachycardia for years

With block

• Supraventricular tachycardia with block in a woman in her fifties.
• A 72 year old man with supraventricular tachycardia with block or slow atrial flutter.
• Supraventricular tachycardia/flutter with increased ventricular response after IV diltiazem.
• A tracing from an 80 year old man post aortic valve replacement.
• A 12 lead EKG from a 72 year old man with supraventricular tachycardia with 2:1 block.
• An elederly woman with a mitral valve replacement.

Atrial Flutter

• Atrial flutter with 4:1 block and RBBB.
• Supraventricular tachycardia/flutter with increased ventricular response after IV diltiazem.
• A wide complex tachycardia (atrial flutter with 1:1 conduction) in a patient with corrected Tetralogy of Fallot. Recorded with a loop monitor.
• A case of tachy-brady syndrome. The recording is from a loop recorder and shows atrial flutter followed by asystole.
• A patient in the hospital with atrial flutter and a slow ventricular response.
• A 65 year old man'
• A man in his 50's before and after adenosine.

Nodal Rhythm:

• Three ECGs (0ne of which is nodal rhythm ) and X-ray from a patient with syncope and chest pain.

Accelerated nodal rhythm

• Nodal rhythm in a woman in her fifties.
• Accellerated nodal rhythm in a woman in her seventies.

Wolf Parkinson White

• WPW in a 55 year old woman
• WPW in a 43 year old man
• Case three
• Case four
• Case five
• Case six

Other atrial rhythms

• 54 year old man with a heart transplant.

Ventricular Arrhythmias

Premature Complexes

• In an 87 year old man.

Bigemini

• PVCs in bigemini in a 75 year old woman.
• PVCs in bigemini in a 75 year old woman #2
• Bigemini in a 60 year old man
• Interpolated PVCs in a 80 year old woman.
• A patient on the hospital ward with PVCs as well as RBBB, Left Posterior Hemiblock, criteria for LAA and RAA.
• PVC couplets.
• PVC salvos

Ventricular Tachycardia

• Two EKG strips from a patient with a failing pacemaker and Torsade de Pointes ventricular tachycardia
• An EKG from a patient in the surgical recovery room showing Torsade de Pointes ventricular tachycardia
• From an elderly woman
• Ventricular tachycardia an elderly woman
• Two ECGs from a patient in an emergency room, first with ventricular tachycardia and then after a shock, sinus rhythm.
• A 66 year old man with fast ventricular tachycardia
• A 35 year old man with an acute inferior wall M.I. and ventricular tachycardia.
• 12 lead recording of ventricular tachycardia with intracardiac recordings in a patient with a dual chamber pacer/defibrillator and a severe intra-ventricular conduction defect.
• VT in 62 year old man with a previous inferior wall myocardial infarction and a history of ventricular tachycardia. This page shows his EKG and an abnormal surface average EKG.

Ventricular Fibrillation

• 12 lead recordings from two patients with ventricular fibrillation
• Ventricular capture beats with paced ventricular rhythm
• A patient with recurrent wide complex tachycardia
• A 70 year old woman with recurrent ventricular tachycardia and a severe intra-ventricular conduction defect.

Implanted Devices

Cardiac Pacemakers

Examples of different pacing modes

DDD pacemakers

• DDD timing diagram in sinus rhythm with an AV delay of 80ms.
• DDD mode showing atrial and ventricular pacing and atrial sensing and venticular pacing.
• DDD mode showing ventricular tracking of atrial fibrillation
• DDI timing diagram in sinus rhythm and with one PVC with an AV delay of 80ms.
• DDI pacing at a lower rate of 50/min
• DDD pacemaker recorded on a 12 lead EKG. Patient has a severe intraventricular conduction abnormality
• DDD pacemaker at its upper rate limit in a patient with atrial fibrillation/flutter
• DDD pacemaker failing to sense a P wave
• DDD pacemaker the effect of a PVC on the timing cycles
• DDD pacemaker timing diagram with atrial lead pacing the ventricle
• A patient with atrial tachycardia with an intra-atrial recording from his pacemaker
• Ladder diagrams and tracings while in DDI mode and complete heart block.
• DDD pacer set at 70/min. but atrial pacing at 75/min due to conduction with a PR interval shorter than the A/V interval set on the pacemaker.
• Recording from the atrial lead of a patient with atrial fibrillation

Atrial pacing

• AAI with ladder diagram
• AAI pacing 12 lead with a patient with Right Ventricular dysplasia taking Flecainide for ventricular tachycardia.
• A series of electrocardiograms from a 78 year old woman who was implanted with a VVI pacemaker in 1991. The patient developed congestive heart failure five years later due to pacemaker syndrome which was corrected by switching to atrial pacing.
• A patient with an atrial pacer that did not seem to pace properly.
• Two rhythm strips from a patient with an AAI.R pacemaker with atrial sensing of the QRS due to a prolonged PR interval.
• 12 lead electrocardiogram of a patient with right ventricular dysplasia and paced rhythm
• A rhythm strip from a patient that shows AAI pacing competing with and resetting the patient's nodal rhythm.
• Atrial pacing with competition from an accelerated ventricular rhythm causing fusion complexes
• An irregular rhythm with an atrial pacemaker.

Ventricular Pacing

• VVI with ladder diagram
• Ventricular paced rhythm with atrial flutter
• VVI pacing in patient with first degree A/V block
• Ventricular paced rhythm with atrial flutter after A/V nodal ablation.
• The effect of an acute myocardial infarction on the EKG of VVI pacing
• Failure to pace or a recording artifact? This is a recording from a patient with a Medtronic implantable defibrillator which also functions as a VVI pacemaker.
• Lead failure in a recently replaced VVI pacemaker.
• Escape/capture bigemini
• A rate responsive pacemaker with a respiratory sensor
• A recording showing rate hysteresis
• Pacing during ventricular fibrillation and failure to capture after a 360 joule shock.

Pacing conduction patterns

• A 12 lead electrocardiogram from a patient with a lead pacing the left ventricle.
• Tracings from a the same patient with right atrial appendage stimulation, R.V. septal and apical stimulation.
• A tracing from a patient with Mobitz I AV block where the AV conduction stops with VDD pacing even with a long sensed to paced interval of 300ms.

Pacemaker interactions

• A patient with two pacemakers, a DDD and a VVI .R which is at end of life
• Myopotential inhibition of a VVI.R pacemaker
• Suppression of a VVI pacemaker with an external pacemaker

Pacemaker Pacing Artifacts

• Bipolar ventricular paced rhythm with atrial flutter after A/V nodal ablation.
• Unipolar ventricular paced rhythm with atrial flutter

Pacemaker Follow-up

Unusual rhythms

• Bigemini with magnet over the pacemaker
• Bigemini with atrial threshold testing
• Conversion of atrial flutter with rapid atrial pacing followed by nodal rhythm

Threshold Testing

• 3 lead rhythm strip with DDD pacemaker and normal magnet response
• Pulse amplitude threshold testing for a ventricular pacemaker

Atrial threshold testing

• Atrial threshold testing in a DDD pacer using the AAI mode
• Atrial threshold testing in a model 2102 pacemaker
• PVCs interfering with ventricular threshold testing
• The effect of a long AV interval on atrial threshold testing of a DDD Pacer
• Threshold testing inducing asystole in a 21 year old patient with congenital complete heart block.
• Two pacemakers, DDD and VVI with atrial capture in one and ventricular in the other

Strength duration curves

• A strength/duration curve from an atrial lead.
• A strength/duration curve from a ventricular lead.

Time dependent capture

• Example one (ventricular)
• Example two (ventricular)
• Example three (ventricular)
• Example four (ventricular)
• Example five (dual chamber pacer)
• Example six (dual chamber pacer)

Pacemaker system failure

• Pacemaker pacing failure and Mobitz II A/V block in a patient with a history of Torsade de Pointe and three degree heart block.
• A patient with a failing ventricular lead due to a subclavian crush.

Trans-telephonic EKG recordings

• Trans-telephonic pacemaker check failure to capture
• Trans-telephonic pacemaker check: Failure to capture. A patient in the high Arctic.
• Trans-telephonic pacemaker check at the MUHC (instructions)

Trans-telephonic Audio recordings

• The EKG and sound of a Medtronic VVI.P pacemaker with the magnet applied near the end of the recording
• Recording of end of life indication with magnet applied to VVI pacemaker
• A pacemaker that required inversion of the programming head for programming. The pacemaker could not be programmed in the usual manner in the pacemaker clinic. The pacemaker was implanted correctly with the conducting window toward the skin, but was a left-sided model which differed from the previous x-ray outline of the right-sided model. Having to invert the programming head suggests a problem with the programming head, inverted implantation of the pacemaker, or because the pacemaker electronics are functioning as a contra-lateral pacemaker.

Defibrillation and Cardioversion

External Cardioversion/defibrillation

• Recording of a series of shocks for Atrial Flutter
• Sinus pause post cardioversion for atrial fibrillation
• An irregular rhythm after cardioversion for atrial fibrillation
• pacing during ventricular fibrillation caused by cardioversion and failure to capture after a 360 joule shock.

Implantable Defibrillators

• Recording from a device during a spontaneous episode of ventricular fibrillation.
• P.A. chest film of a patient with an implantable defibrillator and an epicardial patch and S.V.C. spring electrode.

Threshold Testing

• Defibrillation threshold testing of an implantable defibrillator (successful) followed by ventricular paced rhythm.
• Defibrillation threshold testing of an implantable defibrillator (successful) followed by sinus rhythm.
• Defibrillation threshold testing of an implantable defibrillator (successful) followed by sinus rhythm. Recorded using an external defibrillator.

ECG Recordings

• An electrocardiogram from a patient with a cardiac myoplasty stimulator.
• A problem with atrial capture with a dual chamber pacemaker with a long A/V interval.
• A patient post pacemaker implant. for syncope
• A rate responsive pacemaker with respiratory sensor An ECG strip from the pacemaker clinic.
• A patient post DDD pacemaker implant ECG strip and images from a patient post DDD pacemaker implant.
• Patient with perforation of a temporary transvenous pacemaker Three EKGs and X-ray.

The Normal ECG

• Case One
• Case Two
• Case Three
• Case Four
• Case Five
• Case Six
• Case Seven
• Case Eight
• Case Nine

Super Puzzler

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