What did I see this week? - Cardiac Monitoring Service
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What did I see this week?

By Assoc Prof Harry Mond
October 29, 2020

I often see ECGs on topics I have previously covered and would love to share them with you. This diagnosis was a first for me:

I gave it a name and then checked the literature and it has been reported.

There is a ventricular ectopic every 5th beat; ventricular pentageminy.

To summarize:

This is something I rarely see on Holter monitors but is well known to those who ablate atrial fibrillation triggers in the pulmonary veins. This is seen post-procedure.

The top illustration shows atrial fibrillation with a controlled ventricular response. Below are short fragmented episodes of pulmonary vein firing (red highlight) which cause sinus reset but fail to initiate sustained atrial fibrillation. Effectively, the runs are “trapped” in the pulmonary vein at the junction with the left atrium and cannot conduct. The bradycardia probably reflects high vagal tone.                                           Note there is also atrial bigeminy (yellow highlight).

I have previously shown a similar appearance, where the atrial activity was not fragmented.

This is non-conducted focal atrial tachycardia with sinus reset and Wenckebach block at the ectopic myocardial junction.

Finally this one shows a ventricular couplet (red highlight) and what appears to be an atrial triplet (yellow highlight) in sequence.

The sinus P waves are the red arrows with two being concealed (red stippled and blue). The blue one, however, probably conducts to the ventricle with a very long PR interval which then allows retrograde conduction to the atrium (black arrows) setting up a re-entry circuit. Therefore, not a triplet as one is sinus.

Any better suggestions?

Remember, it’s all in the timing

Harry Mond

About Assoc Prof Harry Mond

In 49+ years as a practicing cardiologist, Assoc Prof Harry Mond has published 260+ published manuscripts & books. A co-founder of Cardiac Monitoring Service, he remains Medical Director and oversees 500K+ heart studies each year.

Download his full profile here.

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