Bizarre Trigeminy
Report:
Atrial fibrillation
Advanced or complete AV block
Ventricular (first triplet) and junctional escape beats
VEBs in couplets
Trigeminy
Small voltage, frontal leads
Vertical heart position
Possible old anteroseptal infarction
Comment:
There is no organised atrial activity. The P-like bump in front of the third QRS in lead 3 has no equivalent in simultaneous 1 and 2. What is seen is consistent with AF.
The first escape beat is bizarre and very likely ectopic ventricular in origin; the other three are narrow, either conducted from AF or, more likely, escape junctional beats.
The couplets that follow the escape beats have slurred descent in V1-2 and a rapid ascent; otherwise they could pass for conducted LBBB beats. There is a tendency for VEBs to emerge in the wake of a beat terminating long pauses – the rule of bigeminy (bigeminy begets bigeminy). In this case it is trigeminy, but the rule can be bent a little to accommodate trigeminy as well.
Below (Fig 180a), with a demand pacemaker in place, the same VEBs form bigeminy. No supraventricular beats are in evidence. AF is still present in the atria.
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