Download ECG of thE Month Irregular Rhythm in a 25-Year

Journal of the Louisiana State Medical Society
ECG of the Month
Irregular Rhythm in a 25-Year-Old Man With
Three Prior Cardiac Operations
D. Luke Glancy, MD; Jameel Ahmed, MD; Siby G. Ayalloore, MD;
Paul A. LeLorier, MD; Pranav M. Diwan, MD; Frederick R. Helmcke, MD
The patient underwent closure of an atrial septal defect at age 3, had a leaking “mitral” valve repaired at
age 9, and at age 13 had a “mitral” valve replacement. He began taking warfarin sodium at that time and
remained symptom-free until 10 days before his initial visit here when he presented to another hospital
with dyspnea and palpitations. Treatment there consisted of lisinopril 10 mg qd, carvedilol 6.25 mg bid,
aldactone 25 mg qd, furosemide 40 mg qd, digoxin 0.25 mg qd, and a continuation of warfarin sodium 7.5
mg qd. An echocardiogram showed a left ventricular ejection fraction of 20%. After diuresis, he was referred
to our cardiology clinic.
On his initial visit here, his heart rate was an irregular 120 beats/min, his blood pressure was 106/77 mmHg,
and closing and opening snaps of a normally functioning mechanical mitral valvular prosthesis were heard.
He was obese (height, 5’ 9”; weight, 272 lbs). An electrocardiogram was recorded (Figure 1).
Figure 1
What is your diagnosis?
Explication is on p. 41
40 J La State Med Soc VOL 165 January/February 2013
ECG of the Month
Presentation is on p. 40
DIAGNOSIS: Coarse atrial fibrillation with a rapid ventricular
response, left anterior fascicular block, left ventricular hypertrophy
with repolarization abnormality.
Coarse atrial fibrillation is characterized by fibrillatory
waves > 0.1 mV (here up to 0.3 mV in lead V1), which
have been considered a sign of left atrial enlargement1,2 and
have been associated with rheumatic heart disease1 and
congenital heart disease,3 whereas fine fibrillatory waves
have been associated with atherosclerotic disease.1 Surawicz,
however, thinks that separating atrial fibrillation into coarse
and fine forms is not justified clinically in the current era.4
Coarse atrial fibrillation is sometimes mistaken for atrial
flutter. Atrial flutter waves, however, all have the same
morphology, including the same height and width, and
the rate is usually 250 - 350 flutter waves/minute. None of
these criteria is met in this electrocardiogram, and the rate
is nearly 450/minute.
Criteria for left anterior fascicular block as proposed by
the World Health Organization/International Society and
Federation of Cardiology (WHO/ISFC) task force are left
axis deviation of the QRS in the frontal plane of -45° to -90°,
qR pattern in aVL, R peak time in aVL >45 ms, and QRS
duration <0.12s.5 The ECG in Figure 1 meets all four of those
criteria and, in addition, shows two other features usually
present in left anterior fascicular block: a rS pattern in the
inferior leads and, because of the broad counterclockwise
loop inscribed by the QRS in the frontal plane, the R wave
peaks in aVL before it peaks in aVR.
The QRS voltage is huge and meets most of the standard
criteria for left ventricular hypertrophy (LVH). In addition,
it meets two criteria for LVH that have been validated in
patients with left anterior fascicular block: S wave in lead
III + largest R+S in any single precordial lead >3.0 mV6 and
SV1 + RV5 + SV5 > 2.5 mV.7
Morphologic and pathophysiological diagnoses in
this patient can be made from the history and the electrocardiogram. The atrioventricular septum in the normal
heart separates the right atrium from the left ventricle.8
Absence of the atrioventricular septum results in a common
atrioventricular junction with a common atrioventricular
valve that may have left and right orifices or a single orifice. Depending on the attachments, or lack thereof, of the
common atrioventricular valve to the atrial and ventricular
septums, there may be a defect in the lowermost portion of
the atrial septum, in the ventricular septum, or both.8 On
the left side of the common valve, there is usually a space
or cleft between the superior and inferior bridging leaflets
such that during systole, part of the left ventricular ejectate
regurgitates into the left atrium and often across the atrial
septal defect into the right atrium.8,9 There may also be incompetence of the right side of the common atrioventricular
valve. A disproportionately long outlet dimension of the
ventricular septum and a narrow subaortic outflow tract
result in the characteristic gooseneck deformity seen on left
ventriculography.
In patients with atrioventricular septal defect, the left
anterior fascicle is hypoplastic and longer than usual, features that probably account for the pattern of left anterior
fascicular block so commonly seen.9 Other electrocardiographic findings may include varying degrees of atrioventricular block and right ventricular hypertrophy if a large
left-to-right shunt and/or pulmonary arterial hypertension
are present.
The cleft in the left side of the common atrioventricular
valve, often erroneously called a cleft in the anterior leaflet
of the mitral valve, is not easily repaired. That despite two
prior open-heart operations our patient required a third to
replace the left side of the common atrioventricular valve
to prevent ventriculoatrial regurgitation is not surprising.
During his six months in our clinic, his ventricular rate has
slowed; his symptoms have disappeared; and his left ventricular ejection fraction, as determined by echocardiogram,
has increased from 20% to 40%. Left atrial enlargement
and left ventricular hypertrophy and dilatation persist.
The mean diastolic pressure gradient across the prosthetic
valve is 6 mmHg, and pulmonary arterial systolic pressure
is <35 mmHg.
REFERENCES
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Thurmann M, Janney JG Jr. The diagnostic importance of
fibrillatory wave size. Circulation 1962;25:991-994.
Peter RH, Morris JJ Jr, McIntosh HD. Relationship of fibrillatory
waves and P waves in the electrocardiogram. Circulation
1966;33:599-606.
Thurmann M. Coarse atrial fibrillation in congenital heart disease.
Circulation 1965;32:290-292.
Surawicz B, Knilans TK. Chou’s Electrocardiography in Clinical
Practice: Adult and Pediatric, 5th edition. Philadelphia: W.B.
Saunders;2001:361.
Willems JL, Demedina EO, Bernard R, et al. World Health
Organization/International Society and Federation of Cardiology
Task Force. Criteria for intraventricular-conduction disturbances
and pre-excitation. J Am Coll Cardiol 1985;5:1261-1275.
Gertsch M, Theler A, Foglia E. Electrocardiographic detection
of left ventricular hypertrophy in the presence of left anterior
fascicular block. Am J Cardiol 1988;61: 1098–1101.
Bozzi G, Figina A. Left anterior hemiblock and electrocardiographic
diagnosis of left ventricular hypertrophy. Adv Cardiol 1976;16:495500.
Ho SY, Baker EJ, Rigby ML, Anderson RH. Color Atlas of Congenital
Heart Disease: Morphologic and Clinical Correlations. London: MosbyWolfe;1995:65-75.
Perloff JK. The Clinical Recognition of Congenital Heart Disease, 4th
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Drs. Glancy, Ahmed, LeLorier, and Helmcke are Faculty, and Drs.
Ayalloore and Diwan are Fellows at Louisiana State University Health
Sciences Center and the Louisiana State University Interim Public
Hospital in New Orleans.
J La State Med Soc VOL 165 January/February 2013
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