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Abstract
Answer
The QRS complexes 1, 2, 4, 5 and 7 are not preceded by atrial activation. The QRS
morphology is slightly different from an A-V conducted beat (QRS 3, 6). Therefore
an origin in the bundle branch system is presumed for beats 1, 2, 4, 5 and 7. An escape
beat (QRS 2, 5) is retrogradely conducted to the atrium with atrial activation followed
by AV conduction and ventricular capture (#3, 6). This phenomenon has been described
previously as escape-echo bigeminy [1]. This echo beat could be the result of dual
AV nodal pathway physiology where the retrograde conduction goes through the slow
pathway. Escape beats 1, 4 and 7 are not conducted antegradely after retrograde atrial
activation. VA conduction of this beat results in slightly earlier atrial activation,
possibly through a fast retrograde AV nodal pathway. Normal sinus rhythm recovered
and the patient was discharged. However, a week later, the patient returned to the
emergency department with symptomatic bradycardia, sinus arrest and chronotropic incompetence
and a pacemaker was implanted. Electrophysiological study performed with the pacemaker
did not show evidence of dual AV nodal physiology.
Sinus node dysfunction during surgical pulmonary vein isolation can result from different
mechanisms: ablation near the vagal nerve can evoke a vagal response; ablation near
the sinus node can inadvertently damage or electrically isolate the sinus node; ablation
near the sinus node artery can result in sinus node ischaemia. In our patient a computed
tomography angiogram revealed that the sinus node artery was a side branch of the
circumflex coronary artery (Fig. 1).
Fig. 1
ECG recording during surgical pulmonary vein isolation
Escape-capture bigeminy is a well-known arrhythmia characterized by group beating of a junctional beat followed by a conducted sinus beat. We report a variant of this arrangement where a junctional beat gives rise to a retrograde P wave, which is then conducted back to the ventricles producing a hitherto undescribed combination (escape-echo bigeminy) resembling escape-capture bigeminy. The clinical significance of escape-echo bigeminy appears similar to that of classic escape-capture bigeminy.
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