|
|
| Line 10: |
Line 10: |
| The questions to address are: '''what is the meaning of the extrasystoles, where do they come from and should further investigations be performed?''' | | The questions to address are: '''what is the meaning of the extrasystoles, where do they come from and should further investigations be performed?''' |
|
| |
|
| [[Puzzle 2005_2_67|Answer]] | | [[Puzzle 2005_2_67 - Answer|Answer]] |
| | |
| [[Image:Puzzle_2005_2_67_fig2.jpg|Figure 1|thumb]]
| |
| Any patient with an old myocardial infarction, reduced
| |
| ejection fraction and occasional palpitations with
| |
| dizziness needs serious attention. The patient is at risk
| |
| for sudden cardiac death and ICD therapy has been
| |
| proposed (the MADIT-II and SCD-Heft studies).
| |
| Holter monitoring should be considered mandatory in
| |
| the work-up. The presence of nonsustained ventricular
| |
| tachycardia, a possible explanation for the symptoms,
| |
| identifies an even higher-risk patient (±30% mortality
| |
| in two years in inducible patients during electrophysiological
| |
| study; MADIT II study).
| |
| The extrasystoles have a right bundle branch block
| |
| morphology indicating an origin from the left ventricle.
| |
| The exact site of origin should be derived from the
| |
| information that comes from the extremity leads. There
| |
| is one extrasystole in the extremity leads exactly at the
| |
| moment that the leads change. Hence it should first be
| |
| decided whether the extra is recorded in leads I, II and
| |
| III or in aVR, aVL and aVF.
| |
| The clue is in the morphology of the extra in these leads.
| |
| A ventricular extrasystole can not be completely positive
| |
| in lead II and completely negative in lead III. The two
| |
| leads are 60° apart and concordantly the morphology
| |
| of the complexes in these leads is usually somewhat
| |
| similar. An opposite complex in aVL and aVF is well
| |
| possible and indicates an origin in the inferior wall. In
| |
| that case, the morphology of the ectopy in II and III
| |
| would also be expected to be negative. Indeed, this was
| |
| the case as shown in figure 2, which is the same ECG
| |
| printed in a different format.
| |
| Hence, the origin of the extras is in the inferior wall
| |
| and thus in the area of the old myocardial infarction. The
| |
| patient needs a serious work-up and an ICD should at
| |
| least be considered (MADIT II, SCD-Heft). In the
| |
| presence of nonsustained VTs on Holter monitoring
| |
| (and inducibility during EPS) a class I indication for
| |
| ICD implantation (according to the NVVC guidelines)
| |
| is established.
| |
