CME INDIA Case Presentation by Dr. Satish Kumar, Cardiologist, Bokaro, Chairman, CSI-Jharkhand. ECG posted by Dr. Mahendra Gawai, DNB Med (3rd yr. std.), Bokaro.

CME INDIA Case Study

• 62-year female came in BGH casualty with C/O Giddiness.
• K/C/O Hypertension 10 years (Telmisartan + Chlorothiazide).
• Past H/O … One episode of syncope – in 2020.
• Vital status /Pulse 40/min; BP 150/90 mmHg.
• ECG changes? Paradoxical venticulophasic CHB?

ECG – 00.43 AM 08/07/2021

Next Morning

ECG 07.40 AM 08/07/2021

Echocardiography

CME INDIA Discussion

Dr Sunil Kumar Sinha, Dhanbad:

Dr Noni G Singha, Dibrugarh, Assam:

• Mobitz type ll AV block.

Dr Satish Kumar, Cardiologist, Bokaro:

• Yes, saw this case.
• In Ventriculophasic Arrhythmia or Reflex, which can occur in Mobitz -II or IIIrd Degree AV dissociation, the PP Interval before the P having a QRS is usually smaller than the PP without QRSs.

• This is most likely CHB, though Mobitz Type II with varying conduction is another possibility.
• If we plot the Ps, including those hidden on Ts, all the PPs are equidistant.
• The peculiarity in the above rhythm is that the alternate smaller QRSs ‘seem’ to be Sinus conducted with fixed PRs.

Dr Virendra Pd Sinha, Assoc. Prof & HOD (Cardiology) Patna Medical College, Patna:

• PR of 2nd, 4th, 6th and 8th ventricular complex are same, and PR of 3rd, 5th,7th are same. So, partial capture Variation in QRS due to variable RBB blockade as clear from lead v1.
• V 1 1st beat more height of terminal r and 2nd less height.

Dr Venkatesh Molio, Maregoan, Goa:

• Mobitz 1 Wenckebach, LAHB, Incomplete RBBB, Sinus rhythm.
• Wenckebach mobutz1, LAHB.
• Incomplete RBBB.

Dr Premchand Singh, Physician, Imphal:

• Complete HB.
• Please note the variable PR interval.
• AV Dissociation.

Dr Shashikant Nigam, MD Med, Ahmedabad:

• CHB. On HBE prolonged AH interval.

Dr John Roshan Jacob, DM, FACC, Assoc. Prof, Cardiology, HOD (EP Unit) CMC Vellore:

• You are right Sir it is third degree AV dissociation.

Dr Balachander, Physician, Chengalpattu Medical College, Chennai:

• Is it Mobitz type 2 block?

Dr Mandar Mahavir Shah, DM (card), Head Dept. of Cardiology, TMH, Jamshedpur:

• Actually, this is not a CHB.
• In CHB, there should be an escape rhythm where RR interval will be constant. Here it is not.
• So, in this ECG, at least some beats are conducted. (Most likely 3rd, 5th, 7th and possibly even 1st).
• This is an example of high-grade AV block. (A high-grade AV block is one where at least two consecutive beats are not conducted to the ventricle).
•  Other alternative explanation is it is a 2:1 block alternating with 3:1 block. Whenever there is 2:1 block, there is longer PR and little more aberrancy.
• 3:1 block is an example of high-grade AV block, whereas pure 2:1 is not.
• A permanent pacemaker is needed.

Dr D P Khaitan, Cardiologist, Gaya:

• There is no possibility of pathological high grade AV block to be converted alternatively  into 2:1 Mobitz type 11 and vice versa unless and until this is a functional higher degree AV block. Due to shorter R R interval before the higher one is most likely  sets in the higher functional AV block with somewhat lengthening of P R interval with more aberrancy – the reason for alternate variable PR interval and alternate change in the configuration of QRS.
• On Holter there might be possibility of intermittent CHB.
• Holter might be very helpful here.
• The nature of AV block seems to be progressive.
• A permanent pacemaker is the answer.

Dr Yash Lokhandwala, MD, DM (Cardiology), FACC (Arrhythmia Associates), Mumbai:

Dr Satish Kumar:

Holter: after the initial A-V dissociation at admission, she has been asymptomatic and maintaining Sinus Rhythm.

CME INDIA Learning Points

• Atrioventricular (AV) block is an AV conduction disorder that can manifest in various settings.
• It can present with varying symptomaticity and severity.
• The electrocardiogram is a key diagnostic tool for management.
• A  careful interpretation in view of the symptoms is necessary to institute the correct management.
• One may require serial ECGs/ careful observation of the ECG monitor/ Holter for complete discloser of arrhythmias
• AV blocks can be divided into supra-, intra- or infra-Hisian. Mobitz Type I AV blocks tend to be from supra-Hisian blocks, whereas Type II AV blocks tend to be infra-Hisian.
• Supra-Hisian AV blocks are generally associated with a better prognosis, as the ensuing escape rhythm tends to be faster and more reliable.
• Many times, it is difficult  determine the type of conduction disturbance producing a fixed ratio block, although clues may be present.
• Mobitz I conduction is more likely to produce narrow QRS complexes.  This type of fixed ratio block tends to improve with atropine and has an overall more benign prognosis.
• Mobitz II conduction typically produces broad QRS complexes. This type of fixed ratio block tends to worsen with atropine and is more likely to progress to 3rd degree heart block or asystole.
• In approximately 25% of cases of Mobitz II, the block is located in the Bundle of His, producing a narrow QRS complex.
• Many times , periods of 2:1 or 3:1 block will be interspersed with more characteristic Wenckebach sequences or runs of Mobitz II.
• As this case is symptomatic and having HIGH GRADE A-V DISSOCIATION, the likelihood of developing CHB is high and should get a pacemaker.
• Alternatively, one may go for EP Study to assess the status of Infra-Hisian conduction before putting in a device.

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