ICU: DDD pacemaker

This is 2 year old postop. patient with DDD pacemaker. What a sinking feeling one gets upon seeing this! (Absolutely no capture of either the atrium or the ventricle).
Click on the image for a larger image.

EKG: Sinus bradycardia with Junctional Escape

4 yr old boy, s/p Ebstein's repair with bioprosthetic valve in tricuspid valve position. Pierre Robin syndrome. Intermittent stridor. Possible vocal paralysis. (Click on the image to enlarge)

EP - What is the diagnosis

7-day old, s/p Norwood Operation. This was observed on the night of surgery.

This is AV block. Is it 2nd degree-type 2 AV block or 3rd degree?

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).

Narrow Complex Tachycardia/SVT - 3 types of responses to Adenosine

Response 1 - Adenosine terminates SVT to sinus rhythm
Response 2 - Adenosine terminates SVT to sinus rhythm; but, SVT returns
Response 3 - Adenosine decreases ventricular response, enabling the correct diagnosis of Atrial Flutter (This narrow complex tachycardia was not SVT)

Thus, if Adenosine does not treat it. It helps to uncover the correct diagnosis! It is important to record EKG strip during Adenosine administration so that the type of response can be carefully analyzed and documented.

EKG - Interpret this

8-day old, 31 week gestation baby. Recovering from Respiratory distress syndrome.

Consulted for episodes of bradycardia.

EKG: PR interval

PR interval appears to be shorted after the ectopies. What is the mechanism?

ICU: What's wrong with this picture...

6-mo old. s/p Complete AVSD repair. Immediate postop. Just arrived from operating room.

Hint: The anomaly is the relationship between LA pressure and PA pressure.
Panel 1 - Has a problem/mistake. (Pardon the shaken image)
Panel 2 - The problem/mistake has been rectified.

Quiz, EKG: What is the rhythm? Junctional vs. Low Atrial rhythm?

11 yr old boy. s/p Repair of Sinus venosus ASD. Started with AAI pacing at 80 bpm in the operating room. You set out to determine the underlying rhythm. The following strips are availabe for analysis. Second-from-the-last panel has atrial lead electrogram in V1. (Click on the images to enlarge).

Last panel image is from Principles of Clinical Electrocardiography by Mervin J. Goldman. Lange Medical Publications. 11th ed. 1982.

Cath Lab: Artifacts in Pressure Traces...Underdamped waveform

Both panels below have LV pressure trace recorded in the same patient.
Upper panel has artifact (Underdamping of the trace)
This artifact is corrected in the lower panel.

What is the mechanism of this artifact (Underdamping)?
What are the methods that can be used to correct such artifact?

EKG - Quiz

5-mo old, VSD closure, Repair of primum ASD and Cleft Mitral Valve. Postop. Day 4. H/O Junctional Ectopic Tachycardia - controlled with Amiodarone for the 2 days.
What is the rhythm?
What is the differential diagnosis?
How would you differentiate between Junctional Rhythm from Sinus rhythm with First degree AV block?
(Click on the image to enlarge)


















Atrial lead is in V1.


















A-paced at 150 bpm.

EP: Quiz, Interpret this EKG recording

You are called to consult for irregular heart rate. A newborn who has recovered from severe sepsis was noted to have irregular heart rate on the day of discharge. Therefore, discharge was canceled and you were consulted. A PICC line was removed the day before. Baby is otherwise doing well. Here are the traces. There are no answers for these traces. Your differential diagnosis and discussion is what is expected.

Quiz: EP - Apparent Malfunction of Pacemaker

1 yr old boy, s/p Mitral Valve replacement, Postop. AV block. Epicardial DDD pacemaker. HR range is set at 110-180 bpm.
First panel (24-hr trend) shows pacemaker heart rate decreased to ~110 bpm between 6pm & 10pm, when the patient was febrile.
Second panel shows EKG prior to drop in HR.
Third panel shows EKG during the low HR at ~110 bpm (with fever).
Fourth panel shows EKG after return of HR to higher level (after fever).
Fifth panel shows current EKG at the time of review (next day).

1) What are the possible reasons for the pacemaker not to respond appropriately during a time of need (fever)?
2) What further information is needed regarding pacemaker settings to determine the cause of this pacemaker behavior?
3) What change, if any need to be made in the pacemaker settings?

EKG: Junctional rhythm with retrograde P wave

3 month old, s/p VSD repair

EKG: RVH with strain - 7 month old

Notable points:
1) What is the significance of upright T wave in a 7-mo old baby?
2) Can you "guestimate" the RV systolic pressure from this EKG?
(Hint: RV1 is 12 mm tall)

EKG: Interpret this rhythm strip

Practice reading the EKG along with calibration marks - for both EKG and Arterial trace.
A-pacing with capture.
Note: Arterial trace has a calibration mark that denotes 55/80/105 mmHg. EKG trace is recorded in 1x standardization.

EP, ICU: Junctional Tachycardia vs. Ventricular Tachycardia

3 mo old infant s/p VSD repair. Postop. day 1.
Note: Paper speed is at 50 mm/sec.
What is the ventricular rate at baseline?
In the second panel, patient is atrially-paced. What do you observe?
Is this junctional ectopic tachycardia or ventricular tachycardia?

(To see a clearer image: Click on the image first. When the new window appears, click on the image again)

EP - Isorhythmic Dissociation

What is isorhythmic dissociation?
These two sets are from the same patient and is supposed to show it.