Thursday, May 08, 2008

EKG Du Jour - #6

Yet another fast and furious EKG Du Jour from the EKG Hall of Shame Fame:

This time, it's a 39 year old who presents from her internist's office after complaining of a 19-year history of palpitations which occur very sporatically. She had been seen by a cardiologist previously who workup was unrevealing: no family history of sudden death or heart disease, normal physical examination, "normal EKG" and "normal echo" (except for "flattening of her mitral valve on parasternal long axis view"). She was labeled as having "probable mitral valve prolapse" and administered Atenolol 25 mg daily, without effect. You, the ever-capable EKG aficionado, obtain this EKG:

Click image to enlarge

You smile, for the answer lies within. What do you tell her?



Anonymous said...

pre-excitation. maybe it wasnt on the previous ECG's?!?

Patrick said...

Well, I see a short PR and a hint of Salvador Dali's moustache. How about doubleyou pee doubleyou.

Anonymous said...

Concur with the previous comments.

If her sx are so sporadic and if no hx of syncope/near syncope, ER visit etc, would you still do EPS and ablate? Is it preferable to actually document the clinical rhythm on event monitor before seeing what is inducible in the lab?


Ablate This! said...

WPW, minimally preexcited because she has a left sided pathway. I would consent her for an EP study and transseptal puncture. It's likely to be around 2 o'clock on mitral annulus (in the LAO projection).

DrWes said...

Oh, there’s no pulling the wool over the blog-o-sphere’s ever watchful eyes. Nice work.

This was a case of the inadvertent diagnosis revealing the true diagnosis – or as I say, “better to be lucky than good.”

In 1930, Drs Wolff, Parkinson, and White published their paper entitled “Bundle-branch block with short P-R interval in healthy young people prone to paroxysmal tachyardia” describing the EKG characteristics of this congenital arrhythmia disorder. This EKG does not have the classically wide QRS complex described by original publication, but it does demonstrate the short PR interval and characteristic “delta wave” of pre-excitation. The initial deflection if the QRS complex gives clues to the origin of the accessory pathway. The upright “R wave” seen in V1 (which is actually the barely-visible delta wave) implies the early activation of the ventricle is moving toward V1 (the only right-sided precordial lead) suggesting the early ventricular activation begins in the left ventricle. This finding, coupled with the “pseudo Q-waves” (again, actually the delta wave) seen in I and aVL, place the accessory pathway on the anterolateral aspect of the mitral annulus (about “2 o’clock” as Ablate This! correctly noted.)

Review of this patient’s old EKG’s failed to demonstrate these findings. It is likely that the administration of the beta blocker slowed conduction in the patient’s normal conduction system enough to demonstrate the pre-excitation seen on this EKG. Because she was so remarkably symptomatic when her attacks occurred, she elected to undergo catheter ablation, which was achieved successfully.

Tom B said...

I barely see it. In the first place, the PR interval is not prolonged (~120 ms in every lead). Physiologic Q waves in the high lateral leads (septal Q waves) are a normal finding. rS complex in lead V1 is not abnormal as long as R/S ratio is < 1. I don't mean to be argumentative, but there is nothing that stands out as grossly abnormal about this 12 lead ECG. The slight slurring of the upstroke of the R wave in leads II, V3, V4, V5, and V6 is dubious grounds to stand to definitively diagnose pre-excitation. The "old" ECG appears to be the key to the correct diagnosis here, although you always have to wonder about correct lead placement. I take it the semi-delta waves disappeared after ablation? This is very subtle! Thanks for sharing.