Atrioventricular block and pause-dependent torsade de pointes

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Atrioventricular block and pause-dependent torsade de pointes Mustafa Dohadwala, MD, Fayak Kamili, MD, NA Mark Estes, MD, FHRS, Munther Homoud, MD, FHRS HeartRhythm Case Reports Volume 3, Issue 2, Pages 115-119 (February 2017) DOI: 10.1016/j.hrcr.2016.08.006 Copyright © 2016 Heart Rhythm Society Terms and Conditions

Figure 1 Electrocardiograms (ECGs). A: ECG from October 2015 with 3:2 AV block. Initially, conducted QRS complexes are narrow with relatively short PR intervals. With subsequent conducted beats, there is slight PR prolongation and a change of QRS morphology to right bundle branch block. B: ECG from January 2016 with initial 2:1 AV block followed by 1:1 AV conduction. The first 3 QRS complexes are narrow. During 1:1 AV conduction, the first QRS complex is narrow and subsequent QRS complexes widen. PR slightly prolongs between the first and second conducted QRS complex and then remains constant. HeartRhythm Case Reports 2017 3, 115-119DOI: (10.1016/j.hrcr.2016.08.006) Copyright © 2016 Heart Rhythm Society Terms and Conditions

Figure 2 Telemetry results in January 2016 are representative of episodes of polymorphic ventricular tachycardia in a setting of short–long–short sequences. A: The pause leading to the run of nonsustained ventricular tachycardia is preceded by a premature ventricular contraction and a nonconducted P wave. B: The pause is preceded only by a nonconducted P wave. HeartRhythm Case Reports 2017 3, 115-119DOI: (10.1016/j.hrcr.2016.08.006) Copyright © 2016 Heart Rhythm Society Terms and Conditions

Figure 3 Ladder diagrams to explain most likely explanation of block in the electrocardiograms (ECGs) presented in Figure 1. A: Referring to the first ECG (Figure 1A), the atrioventricular (AV) prolongation and incomplete left and right bundle branch block are explained by a diseased His-Purkinje system. B: The second ECG (Figure 3B) shows a narrow QRS complex when there is 2:1 AV block (both left and right bundles have opportunity to recover at slower cycle length) but transitions to incomplete left bundle branch block with a faster rate (acceleration-dependent block). A = atrium; AVN = atrioventricular node; HPS = His-Purkinje system; ILBB = incomplete left bundle branch block; IRBB = incomplete right bundle branch block; V = ventricle. HeartRhythm Case Reports 2017 3, 115-119DOI: (10.1016/j.hrcr.2016.08.006) Copyright © 2016 Heart Rhythm Society Terms and Conditions