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      A narrow QRS gallop rhythm

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      Netherlands Heart Journal

      Bohn Stafleu van Loghum

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          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

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          Escape-echo bigeminy.

          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.

            Author and article information

            020-5992387 ,
            Neth Heart J
            Neth Heart J
            Netherlands Heart Journal
            Bohn Stafleu van Loghum (Houten )
            28 January 2015
            28 January 2015
            March 2015
            : 23
            : 3
            : 196
            Department of cardiology and cardiac surgery, Onze Lieve Vrouwe Gasthuis, Oosterpark 9, 1091 AC Amsterdam, The Netherlands
            © The Author(s) 2015

            Open AccessThis article is distributed under the terms of the Creative Commons Attribution License which permits any use, distribution, and reproduction in any medium, provided the original author(s) and the source are credited.

            Rhythm Puzzle - Answer
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            © The Author(s) 2015

            Cardiovascular Medicine


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