Case 27: A 61-Year-Old Man in the Cardiac Surgical ICU
History
Diagnosis
ECG 2
ECG 2 Diagnosis
ECG 3
ECG 3 Diagnosis
ECG 4
ECG Diagnosis
History
This 61-year-old man underwent closure of a large primum atrial septal defect (2.5 cm in width and 2.9 cm in height) with a pericardial patch and repair of a long cleft of the mitral valve. The following ECG was recorded upon admission to the cardiac surgical ICU:
Diagnosis
- AV Dissociation: sinus Rhythm (58/min) with a competing accelerated junctional rhythm (66/min)
- Two AV captures with a long PR interval (490 msec)
- ST elevation, consider pericarditis or injury
Do we see P waves? Yes, there is regular sinus rhythm, rate 58/min
Do the QRS complexes regularly follow the P waves? No, there is a regular narrow-QRS rhythm, rate 66/min, unrelated to the P waves (accelerated junctional rhythm) with 2 shorter RR intervals, due to AV capture (PR = 490 ms)
Conclusion: AV Dissociation: Sinus rhythm with a competing accelerated junctional rhythm, and two AV captures
Do the QRS complexes regularly follow the P waves? No, there is a regular narrow-QRS rhythm, rate 66/min, unrelated to the P waves (accelerated junctional rhythm) with 2 shorter RR intervals, due to AV capture (PR = 490 ms)
Conclusion: AV Dissociation: Sinus rhythm with a competing accelerated junctional rhythm, and two AV captures
ECG 2
One day after his surgery, the following ECG was recorded:
ECG 2 Diagnosis
- Sinus rhythm with first degree AV block (PR = 400 ms)
- ST elevation, consider pericarditis or injury
ECG 3
The following ECG was recored on post-operative day two:
ECG 3 Diagnosis
- Atrial fibrillation with an accelerated junctional pacemaker (ventricular rate 64/min)
- AV dissociation, consider the possibility of complete heart block
- ST elevation, consider pericarditis or injury
ECG 4
The following ECG was recorded eight hours later on post-operative day 2:
ECG Diagnosis
- Atrial flutter with complete AV block
- Ventricular rate 49/min
- Diffuse ST elevation, compatible with acute pericarditis
ECG ID: E704