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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