Case #20 — Tall R Waves in Precordial Electrocardiogram Leads

by Maygen del Castillo, MD, Ihab Hamzeh, MD, FACC, and Yochai Birnbaum, MD, FACC

A 55-year-old man with a history of coronary artery bypass grafting and severe biventricular failure presented with several weeks of shortness of breath and associated chest pain. He needed an Impella® heart pump (Abiomed, Inc.) as mechanical circulatory support for volume overload and cardiogenic shock. His mildly elevated cardiac troponin I level (1.35 ng/mL on admission) was attributed to demand ischemia from decompensated heart failure; the level decreased after diuresis. He was referred for advanced heart failure evaluation. Figure 1 shows his electrocardiogram (ECG) on presentation.

Case #19 — Osborn Waves: Differential Diagnosis

by Akriti G. Jain, MD, Hammad Zafar, MD, Sanjay Jain, MD, and Jason D’Souza, MD

A 56-year-old man with schizoaffective disorder, type 2 diabetes mellitus, and no cardiac history was sent from a psychiatric facility for evaluation of a left foot wound. He was disoriented to time, place, and person. The patient’s core body temperature was 87.4 °F, and his pupils were equally reactive to light. His left foot had an ulcer with a dirty base and much foreign material, and his 2nd and 3rd toes were black with clear demarcation. Laboratory results included a normal white blood cell count (8 ×10⁹/L, 23% band neutrophils), a hemoglobin level of 7.4 g/dL, normal electrolyte levels except for calcium elevation (11.8 mg/dL; 12.8 mg/dL after correction for albumin), and no detected cardiac troponin. Urine toxicology results were positive for tricyclic antidepressants (TCAs). An electrocardiogram (ECG) showed junctional rhythm with J waves (Osborn waves); a corrected QT interval (QTc) of 468 ms; a PR interval of 188 ms; and a heart rate of 60 beats/min (Fig. 1).

Case #18 — ST-Segment Elevation Soon after Coronary Artery Bypass Grafting

by Sanket Borgaonkar, MD, and Yochai Birnbaum, MD, FACC

A 59-year-old woman with hypertension, hyperlipidemia, and gastroesophageal reflux reported exertional angina that resolved with rest and nitroglycerin. Nuclear stress test results revealed a small, reversible inferior-wall defect and a left ventricular ejection fraction (LVEF) of 0.67. A coronary angiogram showed diffuse 3-vessel disease. The patient underwent elective 4-vessel coronary artery bypass grafting (CABG) with no complications and was extubated the next day. On postoperative day 2, a routine electrocardiogram (ECG) showed an rSr′ pattern in leads V₁ and V₂, and ST-segment elevation (STE) in leads V₂ through V₄ (Fig. 1).

Case #17 — Tachycardia in the Presence of Ventricular Pacing

by Toug Tanavin, MD, Mark Pollet, MD, and Yochai Birnbaum, MD, FACC

A 61-year-old man with coronary artery disease presented with volume overload caused by medication noncompliance. His medical history included percutaneous coronary intervention; ischemic cardiomyopathy (left ventricular [LV] ejection fraction, <0.15); and placement of a biventricular implantable cardioverter-defibrillator (ICD), model and programming unknown. Chest radiographs showed properly positioned ventricular and right atrial leads. Figure 1 shows the patient’s electrocardiogram (ECG) on presentation.

Case #16 — Cocaine-Induced Electrocardiographic Phenomenon

by Sundeep Kumar, MD, Luis Sanchez, MD, Ruthvik Srinivasamurthy, MD, and Patrick F. Mathias, MD, FACC

A 27-year-old white man presented at the hospital after recent cocaine use, reporting intermittent left-sided chest pain, diaphoresis, and dizziness. His vital signs were normal; results of physical examination were not noteworthy. Chest radiographic and cardiac enzyme test results were normal. His urine was positive for cocaine. An electrocardiogram (ECG) during a pain-free state revealed findings not present one month earlier: a prolonged QTc interval, new T-wave inversions, and biphasic T waves in leads V₂ and V₃ (Fig. 1, arrows).

Case # 15 — Chest Radiograph Clarifies an Electrocardiographic Abnormality

by Alexander Postalian, MD, Yochai Birnbaum, MD, FACC, and Mohammad Saeed, MD, FACC

A 69-year-old man with severe aortic stenosis underwent transcatheter aortic valve replacement with a 29-mm Edwards Sapien 3 Transcatheter Heart Valve (Edwards Lifesciences LLC). During the procedure, he had transient 3rd-degree atrioventricular block, followed by sinus rhythm with PR prolongation, right bundle branch block, and left anterior fascicular block. Our electrophysiology team was consulted.

We decided to implant a dual chamber pacemaker (Medtronic) in DDDR mode. The day after implantation, the following surface electrocardiogram (ECG) was obtained (programmed atrioventricular [AV] delay, 160 ms).

Case #14 — Slow, But Dangerous

by Kelvin N.V. Bush, MD, and Gregg G. Gerasimon MD

A 70-year-old man with ischemic heart disease, chronic heart failure, and a left ventricular ejection fraction of 0.25 presented with recurrent palpitations and diaphoresis. His single-chamber implantable cardioverter-defibrillator had recently been upgraded to a Dynagen™ X4 Cardiac Resynchronization Therapy Defibrillator (Boston Scientific Corporation), and he had been taking β-blockers and amiodarone. Physical examination results were notable for hemodynamic stability, jugular venous distention, a jugular venous pressure of 12 cm H₂O, and no evidence of pulmonary or hepatic congestion. The patient’s resting electrocardiogram (ECG) revealed a wide-complex rhythm (Fig. 1).

Case #13 — Confusion, Ataxia, and Wide-Complex Tachycardia: What Caused This Arrhythmia?

by Justin Price, MD, Jinesh Shah, MD, Michael Q. Bui, MD, and Christopher D. Chiles, MD, FACC

A previously healthy 36-year-old woman presented at the emergency department with gradual-onset confusion, ataxia, and aphasia. Her vital signs were normal. On physical examination, she reacted to painful stimuli but was nonverbal and unable to follow commands. Initial laboratory results revealed no abnormalities. Computed tomograms of the head and results of a lumbar puncture were nondiagnostic. During hospitalization, the patient decompensated and needed emergency intubation and vasopressor support. An electrocardiogram (ECG) was obtained (Fig. 1). An echocardiogram revealed an acute reduction of left ventricular ejection fraction (range, 0.35–0.40) and anterior wall-motion abnormalities. Notable laboratory results included troponin I, 17.1 ng/mL; normal thyroid values; and negative toxicology screening.

Case #12 — Varying Morphology of QRS Complexes: A Possible Explanation

by Rida Laeeq, MD, Mark Pollet, MD, Nadeen Faza, MD, and Yochai Birnbaum, MD

A 62-year-old man with nonischemic cardiomyopathy (left ventricular [LV] ejection fraction, 0.30–0.34) presented for evaluation of weakness. In 2011, he had undergone placement of a D224TRK Consulta® CRT-D (Medtronic, Inc.; Minneapolis, Minn) biventricular implantable cardioverter-defibrillator. The pacemaker, programmed in DDD mode, had a lower rate limit of 60 beats/min (cycle length, 1,000 ms) and an upper limit of 130 beats/min (cycle length, 430 ms), a paced atrioventricular (AV)-delay period of 130 ms, and a sensed AV-delay period of 100 ms. The LV lead threshold was 1.25 V at 0.6 ms and was programmed to deliver 1.75 V at 0.6 ms. The right atrial and right ventricular leads were in standard positions. The electrocardiogram appeared as follows (Fig. 1).

Case #11 — Is the Pacemaker Functioning Properly?

Alexander Postalian, MD, Mohammad Saeed, MD, J. Alberto Lopez, MD, and Yochai Birnbaum, MD

A 93-year-old woman with no symptoms was admitted to the hospital for a pacemaker generator exchange. She had a history of ischemic cardiomyopathy and was taking optimal medical therapy. She had also experienced paroxysmal atrial arrhythmia, which had been treated with atrioventricular node ablation and dual-chamber permanent pacemaker implantation. Upon her arrival, a 12-lead electrocardiogram was obtained (Fig. 1).

Case #10 — Bigeminy and a Pacemaker

by Luke Cunningham, MD, and Yochai Birnbaum, MD

An 81-year-old woman with a medical history of coronary artery disease, paroxysmal atrial fibrillation, and sick sinus syndrome, and implantation in 2013 of an AltruaTM dual-chamber pacemaker (Boston Scientific Corporation; Natick, Mass), presented after device interrogation revealed elevated impedance of >2,500 Ω in her atrial lead. The device settings were DDD mode, a lower rate limit of 60 beats/min, and a maximum atrioventricular (AV) delay of 330 ms. She reported fatigue, dyspnea on exertion, and occasional palpitations. She was admitted for new atrial lead implantation, and an electrocardiogram was obtained (Fig. 1).

Case #9 — Evaluation of Chest Pain after Implantable Cardioverter-Defibrillator Placement

by Amir Gahremanpour, MD, Mohammad Saeed, MD, and Yochai Birnbaum, MD

A 65-year-old woman with a history of congestive heart failure presented at the emergency department with right-sided upper-chest and shoulder discomfort. Two months prior, she had been given a single-lead Fortify Assura™ VR 1357-40Q implantable cardioverter-defibrillator (ICD) (St. Jude Medical, now part of Abbott Laboratories; St. Paul, Minn). She described her symptoms, which had started 6 hours before admission, as off-and-on pain of mild-to-moderate severity that was not associated with exertion or respiration. She reported no shortness of breath, cough, fever, chills, or dizziness. An electrocardiogram (ECG) was obtained upon presentation (Fig. 1).

Case #8 — A “De-Synching” Feeling

by David A. Burkland, MD, Mohammed Saeed, MD, FACC, and Yochai Birnbaum, MD, FACC

A 78-year-old man presented with worsening dyspnea and edema. He had undergone coronary artery bypass grafting in 2001. At the current presentation, he had ischemic cardiomyopathy with a left ventricular (LV) ejection fraction of 0.20 and was taking home inotropic therapy. Two months previously, he had begun cardiac resynchronization therapy with use of an implanted biventricular pacemaker.

Physical examination revealed elevated jugular venous pressure, bibasilar crackles, and pitting edema above both knees. An electrocardiogram (ECG) was obtained (Fig. 1).

Case #7 — Electrocardiogram Interpretation in a Man with Alcohol Withdrawal and Hypothermia

by Joanna Troulakis, MD, Roman Zeltser, MD, and Amgad N. Makaryus, MD

A 60-year-old man with paroxysmal atrial fibrillation, hypertension, seizure disorder, and alcohol abuse was unresponsive on presentation at the hospital. Laboratory tests revealed hypokalemia (2.5 mg/dL), hypomagnesemia (1.3 mg/dL), and no elevation in cardiac biomarkers. The patient’s admission electrocardiogram (ECG) showed an undetermined rhythm, with further interpretation limited by motion artifact. He was admitted with a diagnosis of alcohol withdrawal and hypothermia. During his hospital stay, he was monitored on telemetry for cardiac manifestations of electrolyte abnormalities. The covering physician was urgently called for suspicious telemetry events that prompted the completion of the following ECG (Fig. 1). 

Case #6 — Proarrhythmic Antiarrhythmic

by Mark Pollet, MD, and Mohammad Saeed, MD

A 56-year-old man with a history of atypical atrial flutter related to atrial septal defect repair presented at the emergency department with palpitations and light-headedness. An electrocardiogram (ECG) was performed (Fig. 1). He had undergone an ablation procedure and therapy with metoprolol and flecainide. He had a history of cardiac arrest and had received a Teligen® model E110 dual-chamber implantable cardioverter-defibrillator (ICD) (Boston Scientific Corporation; Natick, Mass). The ICD was programmed in DDD mode, with a lower rate limit of 60 beats/min and an upper limit of 120 beats/min. Ventricular tachycardia therapy was set to begin at 210 beats/min, and ventricular fibrillation therapy at >230 beats/min.

Case #5 — To Pace or Not to Pace?

by Nadeen N. Faza, MD, Kainat Khalid, MD, Mohammad Saeed, MD, and Yochai Birnbaum, MD, FACC

A 75-year-old man with a medical history of sick sinus syndrome and left bundle branch block presented for evaluation of chest pain. The patient had a dual-chamber permanent pacemaker. Figure 1 shows his electrocardiogram (ECG).

Case #4 — An Unusual Presentation of QT Prolongation

by Mohammad Khalid Mojadidi, MD, Ninel Hovnanians, MD, Michael R. Kaufmann, MD, and James A. Hill, MD, FACC

A 55-year-old woman with a history of chronic bronchitis, Clostridium difficile colitis, and alcohol and tobacco abuse was admitted with altered mentation, hyponatremia, and necrotizing right-upper-lobe pneumonia. She was started on cefepime and vancomycin; metronidazole was added for colitis. A resting electrocardiogram (ECG) showed sinus tachycardia with a QS pattern in the precordial leads, normal intervals, and small T-wave inversions in leads V₅ and V₆. Four days later, significant changes in her baseline telemetry rhythm prompted a repeat 12-lead ECG; the patient’s pulse rate was 75 beats/min with a QT interval of 720 ms and QTc of 746 ms (Fig. 1). Her troponin T level was <0.03 ng/mL, and she had no new symptoms. Her medications at that time were aspirin, metoprolol, lisinopril, cefepime, atorvastatin, pantoprazole, metronidazole, oral vancomycin, and subcutaneous heparin. Her potassium level was 2.9 mEq/L, and her magnesium level was 1.6 mEq/L. An echocardiogram showed severe left ventricular dysfunction with wall motion that suggested stress-induced cardiomyopathy.

Case #3 - Heart Block in a Pacemaker: Does This Mean Trouble?

by Mark Pollet, MD, Yochai Birnbaum, MD, and Alireza Nazeri, MD

We present a finding in a 61-year-old woman whose St. Jude Medical dual-chamber permanent pacemaker had been implanted to treat symptomatic bradycardia. The pacemaker, programmed in DDD mode, had a lower rate limit of 60 beats/min and an upper limit of 120 beats/min, a paced atrioventricular (AV) delay period of 250 ms, and a sensed AV delay period of 225 ms.

Case #2 - Evaluation of Suspected Device Malfunction on ECG

by Luke Cunningham, MD, Henry D. Huang, MD, and Yochai Birnbaum, MD

A 62-year-old man with nonischemic cardiomyopathy, a history of Boston Scientific biventricular implantable cardioverter-defibrillator placement (in 2011), ventricular tachycardia after radiofrequency ablation (April and November 2014), paroxysmal atrial fibrillation, and severe mitral regurgitation presented with acute exacerbation of heart failure. A resting electrocardiogram (ECG) showed normal sequential atrioventricular (AV) pacing at a heart rate of 63 beats/min. Baseline device settings were DDD with a lower rate of 60 beats/min, an upper rate of 115 beats/min, a minimum sensed AV delay of 135 ms, and a minimum paced AV delay of 180 ms. The patient underwent mitral valve replacement. Three days later, the pacemaker rate was increased to 80 beats/min, and an ECG showed pacing concomitantly within the T wave in beats 5 and 13 of the rhythm strip (Fig. 1).

Case #1 - Pacing on the T Wave: What Is the Cause?

by Amir Gahremanpour, MD, Yochai Birnbaum, MD, Tracy A. Holt, BS, and Mohammad Saeed, MD

We present the case of a 50-year-old man who had a dual-chamber pacemaker that was implanted because of symptomatic bradycardia. The pacemaker was programmed in a DDD mode, with a lower rate of 70 beats/min; upper rate, 120 beats/min; paced atrioventricular (AV) delay, 180 ms; sensed AV delay, 150 ms; and V-blanking period, 200 ms.