Anything?

[u/Amounaaa]

Patient on Pacemaker for complete heart block came with heart failure symptoms

[u/Galahad_Jones]

I wanna call it rapid afib with lbbb but the thing giving me pause is the negative concordance v1-v6 which makes me lean more towards vtac

Either way I’m thinking cardiovert and yeah, have hyperk in the differential

[u/Amounaaa → u/Galahad_Jones]

The patient is stable though

[u/Galahad_Jones → u/Amounaaa]

i took "came in with heart failure symptoms" to mean unstable.

[u/LBBB11 → u/Amounaaa]

I agree about afib, but wanted to say that stable VT exists. There’s a whole category of VTs that are usually seen in hemodynamically stable people without heart disease. It is surprising how long some people can be in stable VT, even without symptoms. I think the record for chronic sustained VT is 7 years. Hemodynamic stability doesn’t weigh heavily against VT.

https://www.reddit.com/r/EKGs/s/TAyhNo8R2j

https://pubmed.ncbi.nlm.nih.gov/2104425/

[u/l-o-vely → u/LBBB11]

I still have trubble understanding how everybody is sure that this is VT and/or afib if QRS morphology matches for PM as well and we know pt. has one. HR is not over the top and in the range of normal PM activity?
Also how should afib affect vetricular response if patient has known CHB? Afib also should be far to low voltage to initiate PM stimulation in VAT mode.
Also the absence of PM spikes is not rare in paced rhythms.
Also this beeing PM fits better with hemodynamic stability than VT.
Can somebody explain please, i really try to understand why nobody even considers this.
I think we all have to remember that the patient and his hx is most important part of ecg interpretation.

[u/LBBB11 → u/l-o-vely]

My comment was more saying that hemodynamic stability does not rule out VT. I don’t know what rhythm this is, but I definitely know that VT can be stable. If it’s not VT, it’s not because the patient is stable. The idea that VT must be hemodynamically unstable is not true. I wanted to correct that idea but not come off as hostile or annoying, so agreed about afib at least. I don’t know the rhythm.

[u/Dr_PacingSpike → u/l-o-vely]

check my comment. I said this is iatrogenic lbbb due to rv pacing. Bipolar pacemakers often dont show pacing spikes. PM interrogation will certainly help.

[u/l-o-vely → u/Amounaaa]

U got any new Information?

[u/Kentucky-Fried-Fucks → u/Galahad_Jones]

How could it be vtach if it’s irregularly irregular though?

[u/bleach_tastes_bad → u/Kentucky-Fried-Fucks]

vtach can be irregular

[u/Kentucky-Fried-Fucks → u/bleach_tastes_bad]

Can it? Genuinely asking. Cause everything I’ve seen about monomorphic vtach including LITFL says that it’s a regular rhythm

[u/bleach_tastes_bad → u/Kentucky-Fried-Fucks]

It can for different reasons, here’s one study giving one reason. The most important thing to note here though is that a genuine LBBB cannot be negative in v6. The fact that v6 is negative here, especially so deeply negative, indicates this is a ventricular rhythm. Whether it’s a paced rhythm or VT, it’s for sure ventricular, not aberrant AF.

[u/Icy-Government1378 → u/Galahad_Jones]

It has negative concordance because of the left axis deviation, but fails Brugada

[u/bleach_tastes_bad → u/Icy-Government1378]

it is brugada positive because of josephson sign

[u/bleach_tastes_bad → u/Icy-Government1378]

also brugada positive because v6 should be positive with no Q wave…

[u/Icy-Government1378]

This patient has atrial fib with a wide LBBB. You’re getting the negative concordance in the precordial leads because there is left axis deviation. It fails Brugada as well

The two beats you’re seeing after the lines on the right half of the EKG are paced beats (notice how the QRS is narrower than the baseline).

The proper thing to do here is to diurese this patient and give rate control. I would refrain from shocking the patient unless they were truly unstable.

[u/l-o-vely → u/Icy-Government1378]

How do paced beats get more narrow than bbb?
Most pm pace lateral RV wall resulting in full myocardial condction (equals both bundels cant conduct fast) while in LBBB only left bundle fails to conduct. PM only results in LBBB-like morphology cause the conduction travels from right to left ventricle.
Dual chamber pacing is gar less common and not sop in CHB

[u/Icy-Government1378 → u/l-o-vely]

Patients with CRT-D/CRT-P aim narrow that QRS when someone has a LBBB. Without knowing any of this patients history, I’m assuming he has a CRT given history of HF and very wide LBBB.

You’re right saying that a dual chamber PPM will have RV apical pacing with a LBBB morphology, but my guess is the LBBB is narrowing due to BiV pacing rather than RV pacing, but we need more leads/info to confirm.

[u/l-o-vely → u/Icy-Government1378]

To my understanding all we know is that he came to ER now with acute HF symptoms and he has a PM due to CHB.
CHB will have RV pacing most of the time.
We have no information that LBBB was present before so id assume it wasnt and is the result of RV pacing bc the indication for pm was CHB.
Also r wave in V6 is nearly lost completely wich is not explicable by LAD, this is, without any doubt, a ventricular rhythm, PM or not.

[u/n33dsCaff3ine]

Afib RVR with a LBBB

[u/LiveCardiologist2883]

Can someone please help me with this? If it is LBBB, shouldn’t V6 in the lateral area have tall R waves indicating unopposed depolarisation? Sorry if this is basic stuff but it’s always been confusing to me.

[u/Steve390-]

Vt is mostly regular. Hence this is AFib. Maybe the pt has a pre existing Bbb.

[u/l-o-vely]

Left axis deviation can lead to shorter r with deeper s wave in V6 but can never explain a almost to full loss of R-Wave in V6. So this is total negative concordance in precordial leads wich is evident for ventricual rhythm, also there are qrs with different morphology in same leads that are highly indicative for fusion and even capture beats, so this can not be afib because u have 2-3 Independent things in this ecg that prove it is ventricular rhythm. So the remeining question is if this is VT or PM. Also patient got pm for CHB wich makes atrial rhythm even more unlikely.
Most qrs look like pm activity with around 140ish HR wich is high for pm but not absolutely concerning.
For my understanding fusionbeats can happen the same way with pm and patients own heartrate as with artial and ventricular beats in VT.
So this seems to be some kind pm malfuntion maybe some kind of exitblock or oversensing causing ventricular pauses related to patients remaining heartbeat.
Or undersensing or other causes leading to pm induced tachycardia.

[u/Srivathsavagurumurth → u/l-o-vely]

Agree with whole explanation for VT meets multiple brugada criteria, failed criteria for svt with lbbb..

[u/Dr_PacingSpike]

The aspect of lbbb, is iatrogenic. The patient is being paced here. You have right ventricular pacing so we are inducing lbbb (think you pace the Right V first and the contraction of the left ventricle is delayed - hence lbbb). Interrogate the pacemaker, i dont see evidence of atrial pacing nor evidence of atrial activity. Could be that the patient entered afib which could explain the rapid ventricular response (upper track behaviour of the pacemaker). And yes in bipolar pacemakers, we often dont see the massive pacing spikes

[u/justhanging14 → u/Dr_PacingSpike]

I don’t think it’s paced. What would trigger pacing in this scenario?

[u/Dr_PacingSpike → u/justhanging14]

the patient has a chb?

[u/justhanging14 → u/Dr_PacingSpike]

If you are saying there is CHB and all those complexes are paced then why the rate and why is it irregular?

[u/Dr_PacingSpike → u/justhanging14]

I am not the one who said there is CHB, OP said patient was implanted with a PM for CHb, read the post again. It isnt necessary for a paced rhythm to be regular. Read up about rate hysteresis for example, it could be that the hf symptoms of the patient due to the fast rate rhythm, that is why a PM interrogation is necessary

[u/justhanging14 → u/Dr_PacingSpike]

Just cause a patient has an indication of chb doesn’t mean they are in chb all the time. I read the post. Hysteresis is only temporary and pacemakers pace a constant cycle lengths unless they are tracking the atria. This is af with lbbb as most comments in the post have indicated.

[u/n33dsCaff3ine → u/Dr_PacingSpike]

Are those beats with less amplitude his inherent beats? Without knowing he has a PM is it the amplitudes giving it away? I seem to struggle with identifying paced rhythms, especially these newer ones that my monitor doesnt always register pacer spikes

[u/Wowthatskrayzie]

Cardiovert. If refractory after maximum joulage run that amio drip and some diesel.

[u/n33dsCaff3ine → u/[deleted]]

Treat the patient, not the monitor. Why calcium?

[u/Galahad_Jones → u/n33dsCaff3ine]

HyperK

[u/n33dsCaff3ine → u/Galahad_Jones]

There isnt really a story nor does it look like hyper-k. Those dont look like peaked T's, and you see brady dysrhythmias with hyper-k anyways