Atrial ectopy

Plain and simple, atrial ectopy!


Pacemaker Interrogation - Contact telephone numbers

Medtronic – 800-328 2518
St. Judes Medical – 800-722 3423
Biotronik – 800-547 0394
Intermedics (Guidant/Boston Scientific) – 800-231 2330
Sorin group 800-352-6466

Other: x44505, Pager 22212
Telephone numbers to identify which pacemaker a patient has are provided in a different posting in this blog.

ICU: Permanent Pacemaker

3 yr old, Heterotaxy, s/p Fontan procedure. s/p Permanent pacemaker for sick sinus syndrome. Develops sepsis, returns from percutaneous drainage of pyonephrosis. Dexmedetomidine and ketamine were used for this short interventional radiology procedure. After return to ICU, the child has the following trace on the monitor. Interpret.

1) What is the underlying rhythm?
2) What is the pacemaker set at? Guess the mode and rate.
3) Is there native AV conduction? If yes, what is the native AV interval?
4) What is the AV interval for paced beats?
5) What is the pacemaker doing? What is the final assessment of this patient?
6) Why do the pacing spikes appear irregular?
7) How would you manage this patient? (Further studies tests and evaluations are necessary to make an assessment and management).

(Click on the image to enlarge)


CVP trace: Junctional rhythm vs. Sinus Rhythm

6 week old, s/p Repair of TAPVR.
Upper panel - A-paced at 130 bpm.
Lower panel - No pacing.
Diagnosis is clear from EKG trace itself.
Notice the difference in waveform in CVP trace between the two panels. Name the waves in CVP trace. Which is the prominent wave in CVP in the lower panel (in junctional rhythm).
Also, notice the change in BP between the two panels. (Time display at the right lower corner indicates that the two panels were recorded 1 minute apart from each other). Explain the 2 reasons for the lower BP while in junctional rhythm.

EKG: Postop. pericarditis

6 yr old boy, s/p Resection of subaortic membrane. Stable hemodynamics. ST segment elevation was noted on the monitor about 12 hrs after surgery. Therefore, the EKG in the upper panel was recorded. (Lower panel has the EKG recorded immediately upon arrival to ICU from the operating room ~10 hrs earlier).


ICU: Postop Fontan

3 yr old, s/p Fontan procedure, Postop. 12 hrs.
Comment on the hemodynamic status of this patient based on the monitor display.

CVP trace: PA-IVS

3-month old, PA-IVS, s/p BT shunt only as newborn.
Now, admitted for treatment of pneumonia.
1) Name the prominent wave in CVP trace: Is it "tall" 'a' wave or "tall" 'v' wave?
2) What does it signify if the "tall" wave is 'a' wave?
3) What does it signify if the "tall" wave is 'v' wave? (If it is tall 'v' wave, an echo finding will confirm it. What echo finding is it?)

This is an EKG from the same patient. Pardon the artifacts.

Thrombosis of Mechanical Valve - Flouroscopy

Thrombosis of a Mechanical Mitral Valve
Kevin Christopher Harris, M.D., M.H.Sc., and Andrew I.M. Campbell, M.D.
N Engl J Med 2011; 365:e45December 15, 2011

An 8-year-old girl with a history of congenital mitral stenosis and mitral-valve replacement presented after 1 week of dyspnea on exertion, fatigue, and orthopnea. The patient had not been monitoring her international normalized ratio regularly during the period before presentation. On examination, she had tachypnea, a heart rate of 130 beats per minute, and oxygen saturation of 85 to 87% while she was breathing ambient air. The jugular venous pressure was elevated 4 cm above the sternal angle. She had a faint mechanical S1, a narrowly split S2, and both a grade 2/6 holosystolic murmur and a grade 2/6 diastolic murmur, heard at the apex. A chest radiograph, obtained with the patient in a sitting position, showed interstitial thickening, pulmonary edema, and pleural fluid (Panel A). Echocardiography revealed a dilated left atrium, markedly increased inflow velocity across the mitral valve, mitral regurgitation, and abnormal excursion of the mechanical mitral valve. Fluoroscopy confirmed that one leaflet of the mechanical valve was fixed and the other leaflet had reduced mobility (Panel B [arrows indicate the positions of open leaflets in a normally functioning mechanical valve] and videos). In the operating room, extensive clot and pannus were found on the mechanical valve. The patient underwent replacement of the mechanical mitral valve and recovered uneventfully.