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| [[Puzzle 2005_2_67|Answer]] | | [[Puzzle 2005_2_67|Answer]] |
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| [[Image:Puzzle_2005_2_67_fig2.jpg|Figure 1|thumb]]
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| Any patient with an old myocardial infarction, reduced
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| ejection fraction and occasional palpitations with
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| dizziness needs serious attention. The patient is at risk
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| for sudden cardiac death and ICD therapy has been
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| proposed (the MADIT-II and SCD-Heft studies).
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| Holter monitoring should be considered mandatory in
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| the work-up. The presence of nonsustained ventricular
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| tachycardia, a possible explanation for the symptoms,
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| identifies an even higher-risk patient (±30% mortality
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| in two years in inducible patients during electrophysiological
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| study; MADIT II study).
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| The extrasystoles have a right bundle branch block
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| morphology indicating an origin from the left ventricle.
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| The exact site of origin should be derived from the
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| information that comes from the extremity leads. There
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| is one extrasystole in the extremity leads exactly at the
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| moment that the leads change. Hence it should first be
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| decided whether the extra is recorded in leads I, II and
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| III or in aVR, aVL and aVF.
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| The clue is in the morphology of the extra in these leads.
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| A ventricular extrasystole can not be completely positive
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| in lead II and completely negative in lead III. The two
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| leads are 60° apart and concordantly the morphology
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| of the complexes in these leads is usually somewhat
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| similar. An opposite complex in aVL and aVF is well
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| possible and indicates an origin in the inferior wall. In
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| that case, the morphology of the ectopy in II and III
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| would also be expected to be negative. Indeed, this was
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| the case as shown in figure 2, which is the same ECG
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| printed in a different format.
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| Hence, the origin of the extras is in the inferior wall
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| and thus in the area of the old myocardial infarction. The
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| patient needs a serious work-up and an ICD should at
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| least be considered (MADIT II, SCD-Heft). In the
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| presence of nonsustained VTs on Holter monitoring
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| (and inducibility during EPS) a class I indication for
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| ICD implantation (according to the NVVC guidelines)
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| is established.
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