ECG/X-ray Quiz

1

SPOTTERS

Moderator

Dr Raja Selvarj

Presenter

Dr Praveen Gupta

Date-16.03.2017

JIPMER,

PONDICHERRY(INDIA)

2

Spotter 1Identify the abnormality in the ecg

© 12/02/ 2017, Department of cardiology, JIPMER, Pondicherry, India: ALL RIGHT RESERVED

3

Answer

Sinus rhythm at 84 beats per minute,

PR interval 360 msec, Normal axis, Narrow QRS complex, No ST-T wave changes QT interval 360 msec, QTc-430 msec so the

Ecg suggestive of first degree AV block


4

Spotter-2, What is the ECG abnormality (Tachycardia ECG)…

© 11/03/2017, Department of Cardiology, JIPMER, Pondicherry, India: ALL RIGHT RESERVED

5

Spotter-2(Tachycardia ECG, Rhythm strip)…


6

Spotter-2Tachycardia ECG, Post adenosine injection…


7

Spotter-2Sinus ECG


8

Answer

Narrow complex, regular tachycardia

Rate around 200 beats per minute

P wave were not seen

No significant ST-T wave changes seen

There is no evidence of pre-excitation in the baseline ecg

Diagnosis is Short RP tachycardia

DD AVNRT.

Final diangosis- Patient underwent EPS/ablation at JIPMER, Cardiology department.

EPS was suggestive of Atrial tachycardia with origin from left atrium, posterior in

origin. Patient underwent successful ablation.

9


Tachycardia ECG


10

Spotter 3, Conti…Sinus ECG


11

Description of the ECG

Tachycardia ECG- Regular narrow complex

tachycardia rate 200/minutes, LBBB morphology LAD QRS duration nearly 120 msec No AV dissociation, No P wave, No capture beat No fusion beat

Sinus ECG

Sinus rhythm at around 75 per

minute,

LAD,

No ST-T wave changes,

No evidence of pre-excitaion

12

Answer

Patient underwent Electrophysiological study at Department of

Cardiology, JIPMER, Pondicherry, India, by Dr Raja Selvaraj and his

team.

It was suggestive of Antidromic reentrant tachycardia

with mahaim accessory pathway. Patient underwent

successful radiofrequency ablation Final diagnosis is Mahim fiber tachycardia

13

Electrocardiographic Features of Mahaim fiber

The resting electrocardiogram (ECG) is usually normal

No delta wave with Mahaim fiber conduction

ECG features that suggest Mahaim fibers as the cause of a tachycardia with a left

bundle branch block pattern These include:

QRS axis between 0 and minus 75º

QRS duration of 0.15 seconds or less

R-wave in lead 1

rS complex in lead V1

Precordial transition in lead V4 or later

Cycle length between 220 and 450 milliseconds (heart rates of 130 to 270)http://www.uptodate.com/index

14



15

Diagnosis of the ECG

Narrow complex tachycardia irregularly irregular No visible P wave seen Heart rate around 140 beats per minute ST segment depression with T wave inversion in lead II,III,avF, V4-V6

ECG is suggestive of atrial fibrillation with fast

ventricular effect with digoxin effect

16

Spotter 550 yr/male with chest pain

Identify the abnormality in the ecg, localize the coronary artery involved

© 23/01/2017, Department of cardiology, JIPMER, Pondicherry, India: ALL RIGHT RESERVED

17

Answer

ECG-Sinus rhythm at 100/minute Inferior axis nearly 90 degree in view of equiphasic QRS in lead I Diffuse ST segment depression with T wave inversion in lead

I,II,III,avF,avL, V2-V6 ST segment elevation in lead avR, V1 PR interval 120 msec QT interval 360 msec QTc interval 464 msec The ECG suggestive of ACS/USA/ Most likely artery involved is

LMCA

18

CAG of the patient


CAG, 27/01/2017(Pro no- 18538/ CD No-13338)-Right dominance, LMCA=Ostial 90-95% stenosis, LAD=Ostial 70-80%,LCX= Ostial 70-80%, RCA=Moderte diffuse diseases, max 60-70%. Diagnosis- CAD/TVD/LMCA Diseases.

19



20

Answer

Description of the ECG

Broad complex regular tachycardia at around 200 beats per minute

Right axis deviation

QRS duration around 280 msec

RBBB morphology

No P wave

No capture wave

No fusion beat

Diagnosis-Broad complex tachycardia, Differential diagnosis- Ventricular tachycardia, Or It could be

Supraventricular tachycardia with aberrancy

Patient underwent EPS study and found to have Bundle branch reentrant tachycarida

21

Spotter- 7Identify the abnormality in the ecg

Tachycardia ECG

© 09/03/2017, With permission from RMMCH Hospital, Pondicherry, India: ALL RIGHT RESERVED

22

Spotter- 7 Conti………Identify the abnormality in the ecg

Tachycardia ECG

© 09/03/2017, With permission from RMMCH Hospital, Pondicherry, India: ALL RIGHT RESERVED

23

Spotter- 7 Conti………Identify the abnormality in the ecg

Sinus ECG


24

Answer

Description of the ECG- Broad complex regular tachycardia at heart rate around 190 beats per minute QRS of RBBB morphology QRS duration 240 msec Normal axis No capture beats No fusion beats No AV dissociation seen No visible P wave seen

Negative concordance seen from lead V1-V6, rS seen in lead V6 Final diagnosis- Ventricular tachycardia

25

Approach in a patient of Ventricular tachycardia

26

Spotter 8Identify ECG abnormality


27

Spotter 6 Conti……….Identify Cardiac MRI abnormality in the above patient


28

Answer

Broad complex regular tachycardia with rate around 200 beats per minute, AV dissociation was present with intermittent visible P wave in lead I,II, V1. No capture beats No fusion beat seen Negative QRS concordance seen in lead V1-V5 QRS complex were of LBBB morphology QRS axis being inferior (QRS complex are positive in lead II,III,avF) Diagnosis of this ECG is Ventricular tachycardia with inferior axis Final diagnosis if RVOT VT Cardiac MRI(14.02.2017)-Severe biventricular dysfunction, RVEF-25%, LVEF-22%,

RV free wall and sub tricuspid dyskinesia suggestive of Arrythmogenic right ventricular

cardiomyopathy

29

Spotter 9

Identify the device on the right

side of the chest x-ray Its use? Its present status?

http://www.implantable-device.com/wp-content/

uploads/2011/12

30

Answer- Cardiac Contractility Modulation (CCM)

New innovative device therapy for HF Enhance left ventricular systolic function for

symptomatic patients, irrespective of QRS

duration 80% of HF patients have a narrow QRS Implanting the pacing electrodes to superior

and inferior septum of right ventricle Pulse generator deliver large biphasic current

intermittently during the refractory phase of the

cardiac cycle so as to modulate myocardial

intracellular calcium. Intrinsic contractility of the left ventricle will

be enhancedChest X-ray of a patient who is a CRT non-responder and received CCM in 2009 (Optimizer III at that time). He has significant improvement of heart failure symptoms from NYHA class IV to I. There was left ventricular reverse remodeling and increase in ejection fraction. He is free of heart failure rehospitalization in the past 4 years

Liu M, Fang F, Luo XX, Shlomo BH, Burkhoff D, Chan JY, Chan CP,

Cheung L, Rousso B, Gutterman D, Yu CM. Improvement of long-term

survival by cardiac contractility modulation in heart failure patients: A

case–control study. International journal of cardiology. 2016 Mar

1;206:122-6.

31

Answer- Cardiac Contractility Modulation (CCM)

Improved HF symptoms and quality of life

Left ventricular reverse remodeling

Reduction of HF hospitalization and mortality

Patients with ejection fraction between 20-40%

seems to benefit more than those with ejection

fraction <20%.

Used in Europe and Hong Kong, China.

FDA approval is underway

Newest generation device (Optimizer IVis a

smaller device)

CCM can be a treatment option for CRT

non-responders ©2017,CCM and Optimizer are trademarks of Impulse Dynamics N.V. A Germany, StuttgartALL RIGHT RESERVED

Kwong JS, Sanderson JE, YU CM. Cardiac Contractility Modulation for Heart Failure: A Meta‐Analysis of Randomized Controlled Trials. Pacing and Clinical Electrophysiology. 2012 Sep 1;35(9):1111-8.

32

Spotter 10

Identify the foreign

body shown in x-ray Where it is used Advantage

33

Answer Reveal LINQ Insertable Cardiac Monitor (ICM)

Smallest implantable cardiac monitoring device

February 19, 2014 –Medtronic got U.S. Food and Drug

Administration (FDA) clearance

80 percent smaller than other ICMs

Allows continuously and wirelessly monitor patient's heart

for up to three years, with 20 percent more data memory

than its larger predecessor, Reveal® XT

Provides remote monitoring through the Carelink®

Network.

Physicians notifications to alert them if their patients events

Indicated for patients who experience symptoms such as

dizziness, palpitation, syncope (fainting) and chest pain that

may suggest a cardiac arrhythmia, and for patients at

increased risk for cardiac arrhythmias

MR-Conditional, allowing patients to undergo magnetic

resonance imaging (MRI) if neededMedtronic Announces Global Launch of Miniature Cardiac Monitor, Reveal LINQ(TM) ICM

© 2014,MEDTRONIC, ALL RIGHT RESERVED

34

THANK YOU

Education

ECG/X-ray Quiz