Programming AICD

Problem associated with Drug eluting stent

Atrial fibrillation in a patient with inferior wall myocardial infarction

A 50 years old male came to the emergency with chief complaints of acute onset retrosternal chest pain radiating to left arm along with palpitation and perspiration. ECG of the patient is shown below.

ECG 1 (Click on the ecg to enlarge it)

ECG is showing heart rate of 120 beats per minute, irregularly, irregular, no visible P wave seen, left axis deviation, narrow QRS, there is 2-3 mm ST segment visible in lead II,III, avF, V5,V5 along with ST segment depression in lead I, avL so the ecg is suggestive of acute inferolateral wall myocardial infarction with atrial fibrillation.

ECG 2  (Click on the ecg to enlarge it)

.
Patient was successfully thrombolysed with injection streptokinase therapy after ruling out contraindication.

Final diagnosis of the patient is Inferior wall myocardial infarction with atrial fibrillation with successful thrombolysis.


Thank you

AVNRT presenting as Wide complex tachycardia

A 52 years old male came to the emergency with history of palpitation of one hour duration. There was no history of  Diabetes mellitus, hypertension or coronary artery diseases. ECG of the patient is shown below.

ECG 1(Click on the ecg to enlarge it)

ECG is showing wide QRS complex tachycardia at the rate of 230 beats per minutes, right axis, QRS is of RBBB morphology, after each qrs complex ?? small P waves were seen which were merged into the ST segment,RP interval is 80 msec, shorter than PR interval of 240 mse there is no Fusion complex, no capture beat. Also there is no AV dissociation. So the differential diagnosis of the ECG is either Atrioventricular nodal reentrant tachycardia (AVNRT) or Atrioventricular reentrant tachycardai (AVRT) or rare possibility of ventricular tachycardia (VT).

ECG 2 (Another tachycardia ECG of the patient) 

Sinus ECG

 
ECG is showing normal sinus rhythm at 90 beats per minute, normal axis, no significant ST-T wave changes seen.

Patient underwent Electrophysiological study which showed AVNRT with slow-fast pathway. Patient underwent successful slow pathway ablation.

Lets discuss how to diagnose AVNRT

Thank you.

Praveen Gupta

How to prepare for DM/MCH entrance exam: AIIMS/PGIMER/JIPMER/NEET All India

 How to prepare for DM/Mch entrance exam?. Available on amazon.com. 

Thank you

Dr. Praveen Gupta

Assistant professor

Department of Cardiology

VMMC & Safdarjung Hospital

New Delhi, India

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