Complete Heart Block in Atrial Fibrillation
Report:
Atrial fibrillation
Third degree AV block
Junctional escape rhythm 44/min
LVH with ST/T changes ? incomplete LBBB
Comment:
At times there is a suggestion of flutter-like organised atrial activity, but the baseline is too variable for flutter. The regular junctional rhythm bears no relationship to the atrial activity.
The QRS voltage supports the diagnosis of LVH (which the patient had clinically and echocardiographically) but the lack of septal q wave in 1 and V6 suggests, despite the normal QRS duration, incomplete LBBB. Either can cause the poor R wave progression observed. The intriguing R’ wave in V1 is rather variable and may be an artefact or superimposed AF activity; it is absent from the ECG in (blocked) sinus rhythm with junctional escape rhythm (Fig 81a below).
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