Interpolated Main-Stem Extrasystoles
Report:
Sinus rhythm 80/min
Interpolated junctional or bundle of His (main-stem) extrasystoles
Allorhythmic triplets
Left bundle branch block
Primary T wave changes
Comment:
There is a regular sinus rhythm, even though the initial impression may be of recurrent SVEBs in couplets, the second SVEB being, perhaps, a reentry beat in view of the P wave sandwiched between the SVEBs. The polarity of such P waves may be difficult to tell. However, transposition of sinus P waves shows that all the P waves are sinus!
The premature complexes have the same basic LBBB morphology as the sinus beats: the slight difference may be due to non-phasic aberrant conduction reflecting their junctional provenance. Subsequent PR intervals are prolonged through concealed retrograde conduction and subsequent sinus R-R intervals are slighly shorter (by the amount of previous PR prolongation) than the others. Had the P waves following the extrasystoles been completely blocked, the patient would have common or garden trigeminy93.
The T wave changes are subtle but definite: T waves should be inverted in leads V5 and V6. The pattern was stable over time (Fig 146a below is another Outpatient trace) but it does reflect a myocardial problem.
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