WPW syndrome, left posterior pathway, intermittent pre-excitation

A 19 years old male came with the history of palpitation on and off since last six months.  There was no history of giddiness or syncope. Patient ECG is shown below.

ECG (Click on the image to enlarge it)

ECG is showing sinus rhythm at rate 64 beats per minutes, left axis (as lead I is positive and lead avF is equivocal) PR interval is 80 msecs, positive delta wave present in lead I, V1, negative delta waves are present in lead III,avF so the ECG is suggestive of pre-excitation with short PR interval or WPW syndrome. Now if we apply Arruda algorithm then because V1 is positive with R/S >1 so accessory pathway is located on the left side. Now because the lead avF is negative so the pathway is located in the left posterior or left posterolateral in location.

ECG of the patient was showing intermittent pre-excitation. The second ECG of the patient does not shows any pre-excitation. 

ECG 2(Click on the image to enlarge it)  

ECG is showing normal sinus rhythm at rate 110 beats per minute, normal axis, PR interval 160 msec, there is no evidence of any delta wave or pre-excitation in this ECG.

So the final diagnosis is WPW syndrome with left posterior pathway with intermittent pre-excitation.

Lets discuss how to localise pathway in WPW syndrome.

There are two algorithm.

First one

Another algorithm

Thank you

Praveen Gupta

Inferior wall myocardial infarction with complete heart block

A 65 years old male came with history of acute onset retrosternal chest pain along with perspiration, dizziness and dyspnoea of two hours duration. Patient was chronic smoker but there was  no history of diabetes mellitus or hypertension. Patient ecg is shown below.

ECG 

ECG is showing ST segment elevation in lead II,III, avF, along with ST segment depression in lead I, avL suggestive of acute inferior wall myocardial infarction. There is complete dissociation of P wave and QRS suggestive of AV dissociation suggestive of complete heart block (arrow marks).

Patient was immediately admitted and thrombolysed. Patient improved and achieve normal sinus rhythm and later discharged in stable condition.

Thank you

Praveen Gupta