Rare ECGs
This chapter is not divided into two sections because everyone will be interested in this subject. Another purpose of this chapter is to entertain you — especially ‘old ECG cracks’-and the author himself.
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Rare ECGs
At a Glance and The Full Picture This chapter is not divided into two sections because everyone will be interested in this subject.Another purpose of this chapter is to entertain you - especially 'old ECG cracks' and the author himself.
ventricular action is present. Longer episodes of the arrhythmia persisted also after discontinuing with digoxin. The patient died 7 months later of pneumonia. The arrhythmia is very rare if the strict definition is considered:
ECG and ECG Special
i. different morphology of p waves, without a regular basic rhythm. Generally there are innumerable different p configurations ii. constantly different R- R intervals (completely irregular ventricular response='absolute ventricular arrhythmia' as in atrial fibrillation! ) iii. varying PQ intervals iv. beats with AV block 1° may occur as well as AVescape beats and supraventricular premature beats
ECG 32.1 Multifocal or Chaotic Atrial Rhythm Patient 60 y/m. Severe obstructive lung disease. Hypertension. Digoxin 0.125 mg/day, diuretics. ECG (V/V 2 ): instantaneous rate of 50-85/min. P wave morphology is always different, so are the PQ intervals. Consequently absolute irregularity of the
ECG 32.1
M. Gertsch, The ECG © Springer-Verlag Berlin Heidelberg 2004
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v. the rate is generally 80-IOo/min; tachycardia > 120/min is rare (in those cases the term 'multifocal' atrial tachycardia is used).
I
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The arrhythmia lasts for minutes, hours, or days and has no hemodynamic consequences at a normal rate. However, due to frequent association (in about 50%) with severe chronic obstructive lung disease the prognosis is generally not good. About half of patients die within 6-12 months of the underlying disease. The association with digitalis intake has been described. In our experience degeneration into atrial fibrilla tion is rare but has occasionally been documented. Differential diagnosis: sinus rhythm with multiple atrial premature beats (a generally harmless arrhythmia) [1,2].
ECG 32.2 Absent Pericardium
U2
~ U3
~ U4
aVR
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~ U5
Patient 60 y/m. Severe two-vessel disease (left anterior descending coronary artery (LAD): 90% proximal stenosis; Circumflex (CX): 80% stenosis), normal LV function. ECG: sinus rhythm 58/min. Negative p in leads V/V2 , biphasic p in V/V 4(V5), Frontal QRS axis (AQRS p) + 135°. Striking QRS clockwise rotation. Incomplete right bundle-branch block (iRBBB) with minimal first r wave in V"~ Negative T wave in V2N3'
aVL
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Short Story/Case Report 1 Although the cardiac surgeons were informed about the extensive anatomical clockwise rotation of the patient's heart (detected du ring coronary angiography), they performed a sternotomy. As only apart of the right atrium was visible, the patient was turned on his right side and two bypass grafts were attached to the LAD and CX through a left posterior thoracotomy. This operation lasted more than 5 haurs instead of 2 hours. However, the patient was weH 5 years later. Congenital complete absence of pericardium is extremely rare and may be associated with
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