Weekly EP & ECG rounds at the BIDMC
Editors-In-Chief: Chris Pickett,M.D.; Peter Zimetbaum, M.D.; Mark Josephson, M.D.
View more EP & ECG rounds: Weekly EP & ECG rounds at the BIDMC (Archive)
July 2008
58 year old female admitted to the hospital with shortness of breath for "rule out MI protocol". Cardiac enzymes negative and echo demonstrates normal cardiac structure and function.
Two days following admission: development of chest pain and dyspnea.
This is her ECG on presentation:
This is her ECG on day #2 associated with chest pain and dyspnea:
What is the rhythm and other relevant findings?
- Ventricular Tachycardia
- Atrial fibrillation
- Atrial Flutter
- Acute MI
- 1 and 4
- 2 and 4
The patient had ongoing chest pain and now complained of right flank pain. She was transferred emergently to the cardiac catheterization laboratory where the angiogram demonstrated:
The LAD was treated with thrombectomy and placement of a DES.
Abdominal CT scan confirmed evidence of a right renal infarction. The likely diagnosis was AF related emboli to the LAD and Kidney.
The presumption was that AF had reverted to sinus rhythm prior to the initial day of hospitalization and as atrial mechanical function returned a left atrial appendage clot dislodged.
The cardiac index at the time of PCI was 1.3 and the peak CK reached 11,000.
This is her ECG on presentation:
Why is there RBBB and LAFB and does this require a temporary pacemaker?
This is her telemetry 24 hours after PCI of proximal LAD:
Note the retrograde conduction.
What is the diagnosis and mechanism of this bradyarrhythmia?
- Complete heart block in the AV node
- Complete heart block in the His bundle
- Paroxysmal AV block