EXTRA COPY — ECG Blog #546: I was sent this Tracing ...— EXTRA COPY

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Figure-1: XXXX (To improve visualization — I've digitized the original ECG using PMcardio).

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Figure-2: XXXX

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Acknowledgment: My appreciation to 林柏志 (from Taiwan) and M Shah (from Srinagar, India) — for allowing me to use this case and this tracing.
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THE CASE:

60Y man with CKD history, feels dizziness. A challenging ECG tracing shared for discusson. Thanks to M Shah asking me this one.

 

GREAT case! I don't have time now to draw a laddergram — but I walk thru step-by-step laddergrams in a similar case in my ECG Blog #256 (https://tinyurl.com/KG-Blog-256 ). The mechanism is almost certain to be ESCAPE-CAPTURE with Echo beats that for the most part conduct.

So I will ask 林柏志 and M Shah both for PERMISSION for me to use this case as a future ECG Blog (on which I will draw laddergrams. PLEASE LET ME KNOW if I can use this case!

Otherwise — I'd LOVE to know clinical follow-up — because this 60yo with dizziness DOES have subtle ST segment flattening with taller-than-expected T waves in leads V2,V3 + deeper-than-expected T inversion for simple RBBB conduction in V1 — so I wonder IF recent/acute posterior OMI may be responsible for the bradycardia here with junctional escape?

So — the KEY to this fascinating rhythm is the single sinus conducted beat ( = beat #2 — with the point marked "X" telling us what a "normal" T wave should look like. And while I cannot rule out the possibility of multiple PACs — this looks much more like ALL YELLOW arrows indicate retrograde conduction from junctional escape beats #1,3,6,8,9 and 11).

Beats #3, 4, 6 and 9 then "turn around" such that these "echo beats" on the way back to the atrium are able to ALSO conduct forward to produce echo beats #4,5,7 and 10 (with beat #7 conducting with incomplete rbbb and beat #10 with complete rbbb aberration).

So the underlying rhythm here is sinus bradycardia — which leads to junctional escape — which leads to the retrograde P wave conduction — with my suspicion of need to rule out recent/acute post. OMI as the cause.

Isn't this fascinating? — :)